General about Member Benefits

The services provided by L&T-sairauskassa complement L&T's occupational healthcare, which already provides coverage beyond the statutory requirements.

For medical treatments and examinations, members need to initially pay the full cost themselves and then apply for reimbursement from the sickness fund. Healthcare facilities/providers are not authorized to send bills directly to L&T-sairauskassa. The fund also does not provide payment guarantees for additional benefits covered under Section 14 of the regulations.

An exception is made for the fund's contracted partners with whom a direct reimbursement agreement has been established. When visiting these contracted providers, members only need to pay the deductible portion.

As an example, the most frequently used service is the agreement with pharmacies. Members can obtain Kela-reimbursed medications from these contracted pharmacies by presenting the fund's Kela card, free of charge.

Please note the following:

• Not all prescription medications prescribed by a doctor are eligible for Kela reimbursement. The eligibility for reimbursement is determined by the Pricing Council, not by Kela or the sickness fund.
• The same principles apply to reimbursement for clinical nutrition products, equivalent products, and basic ointments.
• The fund will not reimburse medicines that are part of the initial deductible for medicines from 1 January 2024. Medical reimbursements have an initial deductible of 50 euros per calendar year. You pay for your medication in full yourself until the initial deductible is met. Only after this you will receive medical reimbursement for the products you bought. The initial liability accrues for products included in the reimbursement system.
• If you do not have your Kela card with you at the pharmacy or have not received it yet, pay for the medication in full and request a receipt and reimbursement application form from the pharmacy. Submit them to the fund along with the original payment receipt. The pharmacy can also access information about the sickness fund through Kela's direct reimbursement inquiry service if you authorize them to do so.

The additional benefits provided by the sickness fund are paid on top of the general Kela reimbursement. The conditions for eligibility for additional benefits are as follows, according to the regulations:

1. Necessity of treatment: The treatment or
2. Examination must be necessary for the treatment of the specific illness. Diagnostic tests performed to diagnose the illness are also covered.
3. Necessity of costs: Unnecessary costs will not be reimbursed, even if the treatment itself is necessary. Preventive measures and treatments are also not covered.
4. The examination or treatment must be performed by a properly qualified professional registered in the Central Register of Health Care Professionals maintained by the National Supervisory Authority for Welfare and Health.
5. The examination or treatment must take place in a healthcare facility as defined in Section 3(1) of Chapter 3 of the Sickness Insurance Act.
6. The prescription has been obtained before the examination/treatment.
7. The prescription is valid for one year from the date of issue.
8. Reimbursement is limited to a maximum of 15 times per prescription.