Information in English about the SKGZ and its procedures

The Dutch health care system

The Dutch health care system consists of three tiers. Long term care is provided for on the basis of the Wet langdurige zorg (Long term Care Act), by the so-called zorgkantoren. This is the first tier.

Since 2006, Dutch residents and non-residents who work in the Netherlands are obliged to take out a health insurance based on the Zorgverzekeringswet (Health Insurance Act). These health insurances form the second tier.

The third tier is formed by the insurances offering a complementary coverage, like for dental care.

There are also certain private health insurances, for instance for foreign visitors or Dutch residents who want to settle outside the EU/EER.

Mediation by the Ombudsman

If a problem arises with regard to a health insurance, the consumer must first ask the insurer to reconsider its decision. In case the insurer sticks to its decision or does not answer within four weeks, the consumer can request the Ombudsman to mediate. Mediation is free of charge, but the costs of legal assistance, made by the consumer, are at his own expense. The same applies to the insurer involved.

The current Ombudsman is Mrs. R.P. van Marwijk Kooy MA. She has been appointed by the Board of the SKGZ for a period of four years.

In some cases, the Ombudsman will conclude that there is no room for mediation and inform the consumer why he has reached this conclusion. In others the Ombudsman will contact the health insurer, ask to reconsider its decision by providing unbiased information and/or try to reach some sort of agreement. After this, the consumer will be informed about the outcome, and the Ombudsman will ask him whether the problem is solved. Mediation generally takes about eight weeks.

After this, the consumer may decide to take his case to court or to the Geschillencommissie (Disputes Board). If the consumer chooses to go to court, the procedure with the SKGZ ends.

A ruling by the Geschillencommissie

If the problem is not solved, the consumer can take his case to the Geschillencommissie for a ruling that is binding for both parties. The Geschillencommissie consists of four members. They are appointed by the Board of the SKGZ for a period of four years. The current members are: Mr. G.R.J. de Groot MA (Chariman), Mrs. L. Ritzema MA, Mr. H.A.J. Kroon MA, Mrs. M.T.C.J. Nauta-Sluijs MA, Mr. drs. J.W. Heringa MA. The fee for this procedure is € 37,- and will be reimbursed by the health insurer if the Geschillencommissie decides in favour of the consumer. As with the Ombudsman, the costs of legal assistance, made by the consumer, are at his expense.

After paying the entrance fee, the consumer may be asked to provide additional information. The Geschillencommissie will then contact the health insurer and ask him to file defence. If the problem concerns the coverage of the insurance on the basis of the Health Insurance Act, Zorginstituut Nederland (The National Healthcare Institute) has to be consulted. When the file is complete the hearing will take place, to which the consumer and the health insurer are invited. For both parties it is also possible not to attend the hearing in person but to take part by telephone. Parties are not obliged to be present at the hearing.

Deciding on the matter, the Geschillencommissie takes into account the applicable policy conditions, European and Dutch law, case law, and the guidelines of the insurance industry.

It may take up to 26 weeks before the consumer and the insurer receive the ruling by the Geschillencommissie. This ruling is also published anonymously on our website: www.kpzv.nl. All binding advices can be found here.

The binding advice does not provide an enforcement order. In case the ruling is not complied with by the insurer, the consumer will have to submit the matter to the competent court. This however rarely happens.

Should one of the parties concerned disagree with the outcome of the procedure, he may submit his case to the competent court for a marginal review only.

The regulations of both the Ombudsman and the Geschillencommissie are to be found on this website (Publicaties/reglementen). The regulations determine, among other things, that a request cannot be dealt with by the Ombudsman or the Geschillencommissie in case they are not authorized to do so – for instance because the complaint or dispute regards the Wlz -, or the request is not admissible, for instance because it was submitted too late. A file may, according to the regulations be closed if the request is vexatory, or for lack of cooperation by the consumer.

Further information

This information is in the English language, but if you want to submit a request, and do not speak or write Dutch, you should ask a friend or relative who does, to assist you. Submitting a request is easy. You can fill in a complaint form in here.

The procedures with the Ombudsman and the Geschillencommissie are in the Dutch language. After receiving your request, we will ask your permission to process your personal data and contact the health insurer.

It is not compulsory to have legal assistance, but you are free to seek legal advice. If you have al (legal) representative, you remain responsible for providing information (in time), and for timely payment of the fee. So please make sure you and your representative agree on who does what.

As a consumer, you’re free to withdraw your case at any stage. After the hearing, this is only possible with the consent of the insurer involved.

The European Consumer Centre

After reading this, you may find that you have an insurance with an insurer from another EU/EER member state and the SKGZ is not competent. If this is the case, please contact the European Consumer Centre (ECC). The ECC provides information on your consumer rights within the EU/EER. For further information in English you can visit their website.

Helpful information about Online Dispute Resolution (ODR) and ADR-instances in other EU/EER member states can be found here.

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You may also find useful information on the site of Your Europe.