The Development of Health Insurance in Turkey and its Importance from the Point of View of Medical Ethics

- Ibrahim Basagaoglu, Ph.D.
Department of Medical Ethics, Faculty of Medicine, Istanbul University, Istanbul
TURKEY
Email: ibasagaoglu@tnn.net

- Aysegul Demirhan Erdemir, M.D., Ph.D.
Department of Medical Ethics, Faculty of Medicine, Uludag University, Bursa
TURKEY

Email: ademirer@yahoo.com

Email: ademirer@yahoo.com

Eubios Journal of Asian and International Bioethics 14 (2004), 58-60.


Abstract

Health Insurance shows some periods in Turkey. After the foundation of the Turkish Republic, health insurance developed and had modern characteristics. Some problems are present in the relations between patient and physician in the health insurance today. In the period of Ottoman Empire, both religious social foundations and professional guilds helped poor patients. Some foreign insurance companies opened some bureaus in Turkey after 1850. The Law of Ottoman Insurance Company had come into force in 1892 (1). Afterwards, modern insurance laws were seen in the period of Turkish Republic.

Today, two kinds of health insurances are present in Turkey. One of them is the health insurance belonging to the Official Foundations. Another kind is the special health insurance (2). The persons who sign insurance policy with insurance companies should know some points. These are very important from the point of view of the ethical principles and the relations of patient-physician. In this paper, these subjects are stressed and some results are obtained.


In the Ottoman period, both religious social foundations and professional guilds helped to the poor patients. The needs of the poor patients were provided in some foundations such as guesthouses and hospitals (3). Hospitals were called "darŸsshifa" (healing house in English) (4). Poor patients were treated in the hospitals. These were "wakf" (charitable foundations). These were present in a complex city. But, poor patients didn't have official social security. Modern social insurance began to develop in Turkey in the nineteenth century. The religious beliefs were contrary to the concept of modern insurance. According to The Agreement About Branches of Foreign Anonym Insurance Companies with the date of 1889, all the companies should get permission. So, many insurance companies began to get permission. The Agreement of Ottoman Insurance Company had come into force in 1892 and an Ottoman Insurance Company was founded. In this agreement, we see some articles about the management and aims of the insurance company. Some banks founded the General Ottoman Insurance Company. Turkish National Insurance Company was also founded in 1916. We see many Turkish Insurance Companies and some social security foundation-ship up to 1923. Some of them are Military Retired Cooperation, Civilian Personnel Retired Cooperation. These supported the social life of the personnel. Dilaver Pasha Agreement with the date of 1865 has some articles about the therapies and the compensations of miners.

In the Period of Turkish Republic, some modern laws were seen in the field of health insurance. The Law of the Trade with the date of 1926 regulated the relations between the insured person and insurance company and has some articles belonging to the control of insurance. The Law of Control of Insurance Companies contains articles about the rights of the insured persons. Some articles about the aids of health to the workers are present in the Law of Protection of Health with the date of 1930. The laws about some insurances such as Disease Insurance, Death Insurance, Old Age Insurance etc. were passed between 1930 and 1960. The Law of the Control of Insurance Companies had come into force in 1959 (5).

The Turkish Insurance System developed with some laws such as the Retired Cooperation (1950), The Law of the Control of the Insurance Companies (1959), The Law of the Social Insurances (1965) and so, the health of people was insured. Moreover, the Law of the Socialization of Health Services had come into force in 1961. This law provides that health services reach to everybody. According to another law with the date of 1992, poor patients who provide a green card from the official foundations are treated without fee. The persons who haven't any guarantee from the point of view of the social security, and can not provide the expenses of health services can get a green card. These persons shouldn't give a false knowledge about their economic conditions. Moreover, the persons who want to obtain a green card should know their legal applications. If they change their dwellings, they should inform about their new addresses. The health Ministry should pay their expenses (6).

We can see some ethical problems between patient, insurance company and hospital. Some difficulties may exist in the patients' therapies because of these problems. Because the social insurance hospitals are very crowded in Turkey, the physicians cannot have the time for the therapies of the patients. Sometimes physicians cannot behave emphatically because of their economic, social and professional problems. Patients' number is very much and the physicians should treat about 100-200 patients in a day. Some persons work in some foundations without insurance because their foundations don't want to pay their premiums. So, they cannot be treated when they are ill. As a result, their health hasn't social security. Moreover, they cannot apply for the special insurance company because they are not rich. Moreover, today, many special insurance companies are present in Turkey. The Insurance Premium of the Patient should be in the equal ratio to his(her) treatments' expenses. If the expenses are more than the insurance premium, the payments belonging to the therapies of the patients cannot be made and this condition is against the beneficence principle of the medical ethics. Today, the number of specially insured persons increase in Turkey. But, the person who signs the insurance policy with the insurance companies should know some points. These are very important from the point of view of the ethical principles and the relations of the patient-physician. The names of the diseases of the persons and their therapies' ways should be written on the insurance policy (7). The physician should write a true report about the diagnosis of the insured person's disease. Moreover, two rules are very important (8) :

1) The disease of the patient who makes an agreement with insurance company should be in the list of the diseases of this insurance company (8).

2) If the insured person has a different disease, it should be determined with a report and this disease should be added to the company's disease list. Generally, rich persons apply for the special insurance companies (9).

Conclusion

As a result, health insurance has ethical problems in Turkey. These can be seen both in the fields of special insurance and state insurance. Ethical dilemmas can be seen in the relations of patient-physician and in the foundations of health insurance (10). All of these problems have been stressed in this paper. Moreover, the importance of some laws about the health insurance has been pointed out in Turkey.

References
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7) Demirhan EA. Lectures on Medical History and Medical Ethics. Nobel Tőp Kitabevleri; Istanbul: 1995.p.78-123.
8) Tomes JP. The Health insurance portability and accountability act of 1996, understanding the untikicback laws. J Health Care Finance 1998; 25:55-62.
9) Campbell A,Gillett G,Jones,G. Medical Ethics. Oxford University Press; New York :2002.
10) Horstman K. Technology and the management of trust in insurance medicine.Theoretical Medicine and Bioethics 2000 ; I :39-61.


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