The common belief is that insurance companies cover all medical expenses resulting from traffic accidents. In reality, however, the Social Security Institution (SGK) covers all medical costs for traffic accidents. This makes it important to have a clear agreement with your insurance company when purchasing traffic insurance.
The Condition of an Injured Person in a Traffic Accident
Traffic insurance often lists health expenses as a coverage item, but that does not mean the insurance company directly pays for those medical bills. Because policies include a health coverage clause, many policyholders assume their treatment costs will be paid by the insurance company after an accident. In practice, though, all treatment costs in traffic accidents are covered by SGK. Insurance companies only transfer an amount equal to 10% of the traffic insurance premiums they collect to SGK. This arrangement can create disputes between insurers and policyholders. Between January and September 2020, insurers transferred 1.1 billion Turkish lira to the Social Security Institution for treatment-related purposes. Over the past four years that transferred total has exceeded 5 billion lira.
This raises the question of why insurers make these premium transfers to SGK. Until 2011, insurers themselves were responsible for treatment costs arising from traffic accidents under traffic insurance. A legislative change that year shifted responsibility so that SGK would cover all treatment expenses from traffic accidents. The same law also obligated insurers to remit 10% of collected traffic insurance premiums to SGK. As a result, insurers are no longer required to directly pay treatment costs for traffic accidents; instead they remit a portion of premiums to SGK.
Where Should an Accident Victim Request Payment for Treatment?
Certain points must be considered when seeking coverage for treatment costs after a traffic accident. If a traffic accident victim is treated in a public or private hospital and requires intensive care, intensive care costs are covered by SGK. If treatment continues after intensive care, two options exist. The first option is to continue care at a public hospital. When treatment proceeds in a public hospital, SGK covers all costs within the scope of the premiums transferred from traffic insurance. The other option is to go to a private hospital that has an agreement with SGK. In that case, any price difference charged by the private hospital must be paid. If a private hospital without an SGK agreement is chosen, the patient bears all expenses themselves.
Free Treatment at Public Hospitals
Although treatment at state hospitals is provided free of charge, some traffic insurance holders prefer private hospitals because they pay insurance premiums that they expect to allow private care. In principle, regular premium payments might suggest access to private care should be possible, but in practice certain private treatment costs — for example prosthetic devices — are still paid by the patient. The premiums insurers transfer to SGK do not generally cover caregiver costs, temporary incapacity benefits, prostheses, and similar expenses. This gap creates problems. In some cases intermediaries become involved and demand commissions for arranging coverage of items like prostheses. However, because insurers transfer 10% of collected premiums to SGK, the funds remitted could potentially cover hospital expenses if allocated appropriately.
As long as insurers do not directly cover treatment costs, the health coverage clause in policies has sometimes been taken to court. Although there is no definitive judgment settled on this issue, legal actions continue against insurers that include health coverage in their policies while refusing to pay treatment expenses. A regulatory clarification is needed so that accident victims’ medical expenses are handled more transparently and the scope of health coverage within traffic insurance is clearly defined.