Is SGK Refusing to Pay for Cancer Drugs? A Guide to Smart Drug Lawsuits and Reimbursement

Is SGK Refusing to Pay for Cancer Drugs? A Guide to Smart Drug Lawsuits and Reimbursement

Cancer treatment is an extremely challenging process for both patients and their families, medically and financially. “Smart drugs” and “immunotherapy” (Nivolumab, Pembrolizumab, etc.) methods, which have become life-saving with recent developments in the medical world, are unfortunately not affordable for every budget due to their very high costs. Furthermore, the Social Security Institution (SGK) refuses to pay for a significant portion of these vital drugs on the grounds that they are not on the Health Implementation Communiqué (SUT) lists or are tied to very strict criteria.

But Never Lose Hope! Our legal system and high courts never allow any bureaucratic obstacle or economic justification to take precedence over human life. It is entirely possible to receive the cancer drugs that SGK does not pay for completely free of charge through legal means and to fully recover the money you had to pay out of your own pocket in the past. In light of the most recent decisions of the Court of Cassation and the AYM (Constitutional Court) that protect the patient’s right to life, we have compiled the smart drug lawsuit process that will lift this burden off your shoulders.

1. Why Doesn’t SGK Pay for Cancer Drugs? (The SUT Obstacle)

SGK determines which drugs and treatment methods will be covered through the Health Implementation Communiqué (SUT), taking into account the limitations of public resources and cost principles. As a rule, for a drug’s cost to be paid by the state, it must be included in the “List of Drugs to Be Reimbursed” attached to the SUT.

IMPORTANT: Remember: Human Life is Above Institutional Regulations! According to the decisions of the Court of Cassation and the Council of State, the fact that a drug is not on the SUT list or that the patient does not exactly meet the very strict medical criteria sought in the SUT, such as the stage of the disease, does not mean that the drug will not be paid for by the state. Our courts always place the principles of the “right to life” and the “right to access treatment” guaranteed by the Constitution above the budget calculations of institutions. Therefore, a “Rejection” response from SGK is not the end of the process, but merely the first step of the legal struggle where we will claim your right.

According to the decisions of the Court of Cassation, the fact that a drug is not on the SUT list or that the patient does not exactly meet the strict medical criteria sought in the SUT, such as ECOG performance score or disease stage, does not mean that the state will under no circumstances pay for that drug. The patient’s right to life and right to access treatment are always above institutional regulations.

2. 5 Basic Criteria Sought by Courts for Drug Reimbursement

According to the established jurisprudence of the 10th Civil Chamber of the Court of Cassation, in order for the cost of a cancer drug not covered by the SUT to be covered by SGK, the following legal and medical facts must be proven in the lawsuit:

• Medical Necessity: Determination that the drug in question is of vital importance in the patient’s cancer treatment and its use is mandatory.
• Scientific Efficacy: Establishing that the drug will medically and scientifically make a positive contribution to the patient’s recovery, tumor shrinkage, or the course of the disease.
• Treatment Superiority: Determining that the drug is more effective and beneficial compared to existing classical chemotherapy or other treatment methods currently paid for by SGK.
• Scientific Acceptance: The drug must be a treatment method that has completed the necessary phase studies worldwide and is accepted by international medical authorities.
• Contribution to Quality of Life: Legally, the concept of “recovery” does not only mean the complete disappearance of the disease (absolute cure); extending the patient’s lifespan or improving their quality of life is also a sufficient criterion.

3. Interim Injunction: Can Medication Be Obtained Free of Charge While the Lawsuit Continues?

In cancer treatment, not a single day can be lost; lawsuits taking months can put the patient’s life at risk. Therefore, the most critical step in smart drug lawsuits is the “Interim Injunction” requested at the beginning of the case.

• Purpose of the Injunction Decision: With an injunction obtained from the court at the beginning of the case, the drug is provided free of charge by SGK during the lawsuit without waiting for the case to conclude.
• Approach of the High Courts: The Court of Cassation and regional courts of appeal require an “off-label use permit” obtained from the Turkish Medicines and Medical Devices Agency or serious medical evidence showing urgency to grant an injunction.
• Constitutional Court Assurance: The Constitutional Court also quickly issues injunctions in cases where the patient cannot afford the drug with their own means and their material and spiritual integrity is in danger, protecting patients’ access to medication.

4. How Does the Process Work in Smart Drug Lawsuits?

These lawsuits to be filed against SGK are processes that require complete technical and medical expertise. Unfortunately, randomly filed lawsuits can be rejected due to procedural errors.

Stage of Lawsuit	Action to be Taken	Legal Basis
Step 1: Application and Rejection	First, a written application is made to SGK; upon the institution’s rejection, a lawsuit is filed.	Administrative Procedural Rules
Step 2: Expert Report	The court absolutely obtains a health board report from the medical oncology department of universities for the medical necessity of the drug.	Jurisprudence of the 10th Civil Chamber of the Court of Cassation
Step 3: Calculation Report	Once medical necessity is established, the appropriateness of the drug cost and co-payments, if any, are calculated.	Auditable Calculation Report
Step 4: Retroactive Rights	The fact that the drug was used by paying out of pocket before being included in the SUT list is not an obstacle to reimbursement; past payments can also be requested.	Principle of Equality and Urgency

WARNING: In the event of the patient’s death during the trial process, in order for the heirs not to lose their rights, they must submit their will to continue the case to the court within certain periods from the date of death (for example, within 4 months in AYM processes); otherwise, the case will be dropped. If the inheritance is rejected, the right to litigate completely disappears.

You Are Not Alone in This Difficult Struggle: Get Professional Support

SGK smart drug lawsuits absolutely require the support of an expert attorney in terms of tracking prescriptive periods, analyzing off-label use permits, organizing oncology board reports, and ensuring full compliance with the AYM’s rules on “exhaustion of domestic remedies.” Unfortunately, incorrectly or randomly filed lawsuits can be rejected due to procedural deficiencies and lead to irreparable consequences.

While fighting cancer, you do not have to fight the cumbersome wheels of bureaucracy and legal procedures as well. So that your right to health, time, and future are not hindered by bureaucratic obstacles, to recover the cost of your cancer drugs rejected by SGK with legal interest, and to continue your treatment free of charge with an interim injunction, you can contact us through our communication channels.