The biggest attraction of company health insurance is that, through the care coordinator (szolgáltatásszervező), colleagues typically get to see a specialist after a short wait. After the examination, however, a second act often follows: the private doctor would like to write a referral for a CT scan, the results would need to be presented at a state outpatient clinic, or it turns out that the colleague cannot work for two weeks. At this point we are at the boundary between private care and the state system, and the rules here come not from the insurer but from social-security legislation. This article goes through the three most common questions: referral, test results, sick pay.
- Government Decree 217/1997 names the doctors of publicly funded care among those entitled to issue referrals; as a general rule, a private doctor's referral does not open the way to state specialist care – the private doctor's recommendation has to be taken to the GP, who can issue a referral.
- The state treating doctor uses private test results based on professional judgement; private providers also report to the EESZT (the national e-health system), so the results are typically visible electronically too, but the state doctor is responsible for the diagnosis and treatment.
- Under Government Decree 102/1995, incapacity for work may be certified by a GP contracted with NEAK (the National Health Insurance Fund), a designated specialist and a hospital; according to the Hungarian State Treasury, a private doctor – apart from certificates issued by a private hospital – is not entitled to do so.
Referral: can a private doctor refer to a state specialist clinic?
The implementing decree of the Health Insurance Act, Government Decree 217/1997 (XII. 1.), lists in Section 2(2) who is entitled to issue referrals: the GP, doctors in outpatient specialist care and other doctors in the publicly funded care system. As a general rule, a referral from a doctor at a non-publicly-funded – private – healthcare provider does not open the way to publicly funded specialist care; Section 4(1)(a) of the decree names a single case in which inpatient care is available on the basis of such a referral: if, according to the doctor's finding, there is an immediate danger to life. In practice, therefore, the private doctor's recommendation has to be taken to the GP, who issues the referral based on their own professional judgement – the GP is not obliged to adopt the private doctor's request automatically, but in light of the test results typically does so. If the private provider has a financing contract with NEAK (the National Health Insurance Fund) for the care in question, its doctor can issue referrals; it is worth asking the care coordinator about this.
There are two lifelines. Under Section 2(1) of the decree, several specialist clinics can be visited without a referral – including dermatology, gynaecology, urology, psychiatry and addiction medicine, ear, nose and throat, ophthalmology, general and trauma surgery, and oncology. The other: if the package includes it, diagnostics – laboratory tests, ultrasound, certain imaging – can be carried out privately within the package limit, and the cross-over question does not even arise; what fits within the limit is covered in our article on diagnostics. Under the decree, a referral that has been issued can, as a general rule, be used within 90 days of issue; for certain types of care the referring doctor may specify a longer period.
Test results: will the state doctor accept what the private clinic wrote?
The short answer: they will use them, but they are not obliged to reach the same conclusion. Private healthcare providers are also required to connect to the Electronic Health Service Space (EESZT) and upload care events and test results to it, so the results of a private examination – depending on the patient's digital self-determination settings – are also visible to the state treating doctor. Nevertheless, we recommend that colleagues also take the results with them on paper or as a PDF, because the full medical history is not always opened in the consulting room. The state doctor treats private test results as professional evidence: if they are recent and of adequate quality, the examination is typically not repeated; if in doubt, the doctor may order a new one. This is not distrust but a question of responsibility – the doctor who orders the diagnosis and treatment is responsible for them. For a serious diagnosis, it is therefore worth using the second-opinion option as well, if the package includes it.
Sick pay: who can certify incapacity for work?
This is the question with the biggest financial stakes, and the rule here is strict. Under Section 2 of Government Decree 102/1995 (VIII. 25.) on the medical assessment of incapacity for work, incapacity for work is certified by the GP, the doctor in outpatient specialist care, the specialist at the listed care centres, or, for the duration of hospital treatment, the hospital – the GP if they have a contract with NEAK, and the specialist if they have been designated for this purpose by the head of an institution with a NEAK financing contract. The Hungarian State Treasury's guidance sums this up in one sentence: a private doctor – apart from certificates issued by a private hospital – is not entitled to certify incapacity for work. In practice, therefore, the colleague has to take the “unfit for work” recommendation of the private specialist visited through the package to the GP, who places the colleague on sick leave based on their own examination and the test results; retroactive certification is possible only in a narrow range of cases, so this should not be put off for days. Private hospital care is an exception: since the amendment of the decree at the end of 2023 (Government Decree 659/2023 (XII. 28.)), a hospital providing non-publicly-funded care may also certify the incapacity for work of a patient it treats for the duration of the hospital treatment, for cases starting after 30 June 2024 – so after an operation at a private clinic, the certificate for the in-patient stay is typically issued by the clinic itself, while for recovery after discharge it is the GP who places the colleague on sick leave. Under the decree, the certificate can now also be transmitted electronically, so the employee will not necessarily receive a paper copy.
What is at stake: sick leave, sick pay, the package
First comes sick leave of fifteen working days per calendar year under the Labour Code (Mt. Section 126), paid at seventy per cent of absence pay (távolléti díj) (Mt. Section 146(5)) – this, too, is based only on a certificate from an authorised doctor. Then comes sick pay: under Section 48 of the Health Insurance Act (Ebtv.), sixty per cent of the daily base, or fifty per cent in certain cases, subject to an upper limit of one-thirtieth of twice the minimum wage. This loss of income is what group health insurance does not replace on its own: a service-financing package organises care, it does not pay money. If the company wants to close this gap too, a daily benefit for incapacity for work should be sought among the life and accident insurance elements – our article on combined benefits covers this. What private care actually brings is time: shorter waiting times until diagnosis and the start of treatment.
What should HR tell the team?
Three sentences in the employee guide are usually enough: take the private doctor's test results to your GP; for state specialist care and sick pay, it is the GP who can refer you or place you on sick leave; if the package includes diagnostics, book it through the care coordinator rather than struggling with a referral. If a colleague gets stuck – does not know whom to turn to, or the private clinic has not issued a certificate – the steps in our HR guide and the care coordinator's customer line are the first port of call. This boundary is worth stating honestly in the employee guide: the package organises access to private care but does not override the rules of the state system – yet the two complement each other well if the team knows which door to knock on and when.
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Sources
- Government Decree 217/1997 (XII. 1.) Sections 2, 3/A and 4 – care available without a referral, persons entitled to issue referrals, validity of referrals
- Government Decree 102/1995 (VIII. 25.) Sections 2, 10 and 16 – persons entitled to assess incapacity for work, method of certification, non-publicly-funded hospitals
- Hungarian State Treasury (Magyar Államkincstár) – Incapacity for work (who can certify it; private doctors)
- Adópraxis – 2024 changes to the rules on incapacity for work (certification by non-publicly-funded hospitals)
- Health Insurance Act (Ebtv., Act LXXXIII of 1997) Section 48 – rate and upper limit of sick pay
- Hungarian Labour Code (Mt., Act I of 2012) Section 126 and Section 146(5) – sick leave and its pay
- EESZT information portal – For private providers (obligation to connect and to report data)
