A health insurance company’s decision to deny coverage for an uncategorized drug is not subject to judicial review in administrative courts
Legal principle stated by the Court:
When issuing an opinion on whether or not to approve reimbursement for a drug that is not included in the list of categorized drugs pursuant to Section 88(9) and (10) of Act No. 363/2011 Coll., the health insurance company does not act as a public administration body under Section 4 of the Administrative Court Code; therefore, the legal acts issued by it are not decisions within the meaning of Section 3(1)(b) of the Administrative Court Code or measures under letter c) of that provision. These acts are private-law acts in the course of the health insurance company’s operations. Such a matter is excluded from judicial review under Section 7(d) of the Administrative Court Code, and pursuant to Section 3 of the Civil Procedure Code, the court has jurisdiction to hear it in civil proceedings.
On February 18, 2026, the Grand Panel of the Supreme Administrative Court, in its judgment Case No. 19SVs/3/2025, quashed the judgment of the Administrative Court in Banská Bystrica (hereinafter the “Administrative Court”) in proceedings concerning the review of the legality of a health insurance company’s decisions regarding the reimbursement of registered drugs not included in the list of categorized drugs. The Supreme Administrative Court ruled that, in such a case, the health insurance company does not act as a public administration body and the matter is excluded from judicial review within the framework of administrative justice.
The health insurance company issued a repeated refusal to reimburse the cost of a drug not included in the list of categorized drugs. In the reasoning for its decision, it pointed out that reimbursement of the drug would jeopardize the financial sustainability of the public health insurance system by exceeding the budget allocated in the business and financial plan for drug reimbursement for the relevant calendar year.
The Administrative Court overturned the health insurance company’s decisions and pointed out that the justification for refusing to reimburse the medication—namely, that the budget for reimbursing exceptional medications would be exceeded during the calendar year—cannot serve as grounds for refusing reimbursement, as this would unjustifiably favor applicants who submitted their requests at the beginning of the calendar year over those who submitted them during or at the end of the year.
The health insurance company filed a cassation complaint against the administrative court’s judgment, arguing primarily that, when approving reimbursement for an exception drug, it does not act in the capacity of a public administration body and therefore the contested decisions refusing reimbursement for an uncategorized drug are not subject to judicial review within the framework of administrative justice.
By its ruling No. 7Ssk/86/2024 dated June 26, 2025, the Panel of the Supreme Administrative Court referred the case to the Grand Panel of the Supreme Administrative Court for a decision, because even though the existing case law of neither the Supreme Court nor the Supreme Administrative Court has directly addressed the assessment of a health insurance company’s role in approving reimbursement for an uncategorized drug under Section 88(9) et seq. of Act No. 363/2011 Coll., in similar cases, the Supreme Court has concluded that review by administrative courts is permissible in cases where the relevant law does not define consent to the provision of health care as an individual administrative act and it is granted without institutionalizing a specific process for its adoption.
The Grand Panel of the Supreme Administrative Court noted at the outset that a health insurance company is a public limited company (a legal person under private law) established for the purpose of providing public health insurance, and that from a legal perspective, there is no difference between the legal nature of the acts of a health insurance company and those of any other public limited company or other business entity. According to Section 4(d) of the Administration Court Code, a public administration body is a legal entity to which a special regulation has entrusted the decision-making regarding the rights, legally protected interests, and obligations of natural or legal persons in the field of public administration. Special Act No. 581/2004 Coll., in the provisions of Sections 6 and 6b, defines the individual activities of a health insurance company and simultaneously delegates to the health insurance company the authority to decide on the rights and obligations of natural persons and legal entities. The law does not specify a case where a health insurance company would decide on granting or denying approval for special reimbursement of a medication as a delegated exercise of a public administration authority.
The role of the health insurance company is generally to reimburse for healthcare provided in accordance with Act No. 577/2004 Coll. or Act No. 363/2011 Coll., and the mechanism for reimbursement of healthcare provided is governed by private-law instruments — contracts with other private-law subjects.
The reimbursement of medications that are not mandatorily covered by public health insurance falls within the scope of a health insurance company’s autonomy in managing its assets. The insurance company decides on the reimbursement of medications on an exceptional basis according to criteria it determines and publishes on its website. The Grand Panel stated that when approving special reimbursements, the health insurance company does not issue individual administrative acts and does not act as a public administration body.
The private-law nature of disputes concerning the reimbursement of healthcare services between healthcare providers or insured persons on one hand and health insurance companies on the other has long been accepted by the civil courts, which review the merits of such lawsuits. The Grand Panel noted that the position of health insurance companies has, in certain aspects, the character of a factual dominant position given its limited number. However, the possible factual dependency and imbalance between the insured person and the insurance company, resulting from the latter’s position, cannot be mistaken for the authority-based nature of the insurance company’s activities. The Grand Panel concluded that the legal provisions of § 88(9) and (10) of Act No. 363/2011 Coll. does not delegate public authority powers to the health insurance company within the framework of public administration, and the health insurance company expresses its consent or refusal to reimburse an uncategorized drug as a legal entity through a private-law act. The matter under consideration is therefore a private law matter, which is excluded from judicial review under Section 7(d) of the Administrative Court Code, and the court has authority to hear it in civil proceedings under Section 3 of the Civil Procedure Code.
For the reasons stated above, the Grand Panel, acting as the Cassation Court, quashed the contested judgment of the Administration Court and referred the case to the competent civil court for further proceedings.
The President of the Grand Panel JUDr. Marián Trenčan, a member of the Grand Panel JUDr. Petra Príbelská, and another member of the Grand Panel JUDr. Marián Fečík attached dissenting opinions to the judgment of the Grand Panel of the Supreme Administrative Court.
The Supreme Administrative Court issued this ruling by a 4-3 vote. No appeal may be filed against it.
The case was decided by the Grand Panel of the Supreme Administrative Court, composed of: the President of the Grand Panel JUDr. Marián Trenčan and of members of the Grand Panel JUDr. Petra Príbelská, PhD., prof. JUDr. PhDr. Peter Potásch, PhD., JUDr. Marián Fečík, JUDr. Jana Martinčeková (judge-rapporteur), Mgr. Michal Novotný and JUDr. Martin Tiso.