Social Welfare Consolidation Act 2005

• Permanent Page URL

Cost of medical care.

[1993 s65(1); 2005 (SW&P) s23, 26 & Sch 1, 4]

86.—(1) Subject to this section, the cost of medical care which, in the opinion of the Minister, is reasonably and necessarily incurred by an insured person as a result of an injury or disease against which, when it was sustained or contracted, he or she was insured under this Part, shall be payable out of the Social Insurance Fund to the extent that the cost is not met under—

(a) the Health Acts 1947 to 2005, or

(b) the Mental Health Acts 1945 to 2001, or

(c) regulations made under section 138 .

(2) Where an insured person is eligible to avail himself or herself of services provided under the Health Acts 1947 to 2005 or the Mental Health Acts 1945 to 2001 or treatment benefit under regulations made under section 138 but does not do so, the amount payable under this section shall not exceed that which would have been payable had he or she availed himself or herself of those services or that benefit.

(3) Where an insured person receives medical care during any period in which he or she is an in-patient in a hospital or similar institution, the amount payable under this section in respect of that care shall not exceed—

(a) the maximum amount which would be chargeable under section 53 of the Health Act 1970 to an insured person to whom the institutional services provided under that section are made available for that period, or

(b) the maximum amount which would be chargeable under section 231A of the Mental Treatment Act 1945 (inserted by section 71 of the Health Act 1953 ) to an insured person to whom mental hospital assistance is made available for that period,

as may be appropriate.

(4) The amount payable under this section in respect of medical care provided otherwise than during a period in which the insured person is an in-patient in a hospital or similar institution shall be the sum that is, in the opinion of the Minister, reasonably appropriate to the care afforded, having regard to the reasonable necessity for that care and the customary charge for that care.

(5)  (a) Where an insured person requires medical care as a result of an injury or disease against which, when it was sustained or contracted, the person was insured under this Part, he or she or any other person who may be prescribed shall, within the period that may be prescribed, give written notice to the Minister of the care required by him or her, and shall give any particulars that may be required of that care.

(b) No payment under this section shall be made unless the notice referred to in paragraph (a) is given and, where any particulars are required under that paragraph, those particulars are given.

(6) Where notice is given under subsection (5), the insured person may be required to submit himself or herself to medical examination for the purpose of establishing that the medical care is necessary as a result of the relevant accident or disease and that it is reasonable in his or her case, and no payment shall be made under this section where the person fails to comply with the requirement.

(7) Payments under this section shall be made to those persons that the Minister thinks fit and, in particular, where the cost of the medical care payable under this section is due to the Executive, payment may be made to the Executive.

(8) Regulations may provide for applying in relation to payments under this section any of the provisions of this Part relating to benefit and to the making of claims, subject to any additions or modifications.

(9) For the purposes of this section medical care shall comprise, subject to any additions which may be made by regulations—

(a) general practitioner and specialist care, including domiciliary visiting,

(b) nursing care at home except where the cost is met by an increase under section 78 in respect of constant attendance, and nursing care and maintenance in hospitals, convalescent homes, sanatoria or other medical institutions,

(c) pharmaceutical and other medical or surgical supplies, including prosthetic and aural appliances, prescribed by a registered medical practitioner, kept in repair and replaced where necessary,

(d) dental and optical treatment and appliances,

(e) the care given, on the prescription of a registered medical practitioner, by members of professions allied to the medical profession, including physiotherapists and chiropodists, and

(f) conveyance to and from the place where medical care as specified in this subsection is provided.