Decision No. 10 of 4 November 2025 on Constitutional Case No. 32/2024
Referring Authority and Subject Matter of the Case
The case was initiated on 6 November 2024 upon a request by a three-member panel of the Third Division of the Supreme Administrative Court, First Chamber, seeking a declaration of unconstitutionality of the provisions of Article 55, paragraph 2, items 3b and 3c of the Health Insurance Act. The referring court states in its request that the administrative case pending before it, No. 10774/2023, was instituted upon a complaint lodged by the National Association of Private Hospitals against provisions of National Framework Agreement No. RD-NS-01-2 of 1 September 2023 on medical activities, concluded between the National Health Insurance Fund (NHIF) and the Bulgarian Medical Association (BMA) for the period 2023-2025.
The applicant maintains that the provisions of Article 55, paragraph 2, items 3b and 3c of the Health Insurance Act are contrary to Article 4, paragraph 1, Article 19, paragraphs 1 and 3, and Article 52, paragraphs 1 and 2 of the Constitution of the Republic of Bulgaria.
Summary of the Court’s Reasoning
With regard to the provision of Article 55, paragraph 2, item 3b of the Health Insurance Act, the Court finds that the stated objective of the contested statutory provision -namely, to ensure that hospital healthcare establishments are adequately staffed with medical specialists by guaranteeing, by law, certain minimum levels of remuneration - is of constitutional rank and is aimed at securing the exercise of fundamental constitutional rights of citizens, such as the right to health and the right to work. The Court further notes that the establishment by law of mandatory minimum remuneration for medical specialists is constitutionally justified also in view of the fact that state control over the activities of all healthcare establishments has been elevated to a constitutional principle (Article 52, paragraph 5 of the Constitution), since such activity is intended to safeguard supreme constitutional values - namely, the life and health of citizens. The Court emphasizes that guaranteeing a mandatory minimum threshold of remuneration for medical specialists binds equally all hospital healthcare establishments receiving funds from the budget of the National Health Insurance Fund under contracts for the purchase of medical services and, in that sense, does not impair their equal treatment.
With regard to the provision of Article 55, paragraph 2, item 3c(a) of the Health Insurance Act: The contested provision stipulates that the National Framework Agreements on medical and dental activities must contain a methodology for financing the provision of medical personnel in healthcare establishments that perform medical activities in settlements located in hard-to-reach and/or remote areas or that are the sole providers of the respective activity within the territory of the municipality. The Court finds that, in view of its content and the objectives pursued by the legislature, the contested statutory regulation is aimed at protecting the internationally recognised and constitutionally guaranteed right to accessible medical care of those citizens who must not be placed in a less favourable position than other citizens due to their territorial connection to a particular area which, for reasons beyond their control and capacity, lacks the necessary healthcare infrastructure.
The Court holds that the freedom of economic initiative of natural and legal persons under Article 19, paragraph 1 of the Constitution is not only objectively incapable of ensuring the realisation of citizens’ right to health, but, within the meaning of the Constitution, cannot relieve the State of its obligation to guarantee that right under conditions of equality among those entitled to it.
The Court finds that the contested provision does not contravene Article 19 of the Constitution, as it does not place the respective category of healthcare establishments in a more favourable position than other healthcare establishments providing medical services within the territory of the country, since the two categories are not in an identical or comparable situation. In substance, the contested statutory provision is aimed at guaranteeing the right to accessible medical care of citizens in regions that objectively lack such access for geographical and infrastructural reasons. Thus, the law not only does not create inequality; on the contrary, it is specifically intended to overcome inequality in access to hospital care among citizens in different regions of the country.
With regard to the provision of Article 55, paragraph 2, item 3c(b) of the Health Insurance Act, the Court finds that the contested statutory regulation, intended to ensure the remuneration of medical specialists in a specific category of hospital healthcare establishments that are of determining importance for the provision of specialised medical care, pursues a legitimate objective of constitutional rank - namely, guaranteeing citizens’ right to health, which, within the meaning of the Constitution, constitutes an obligation of the State.
This regulation does not place one category of hospital healthcare establishments in a “more favourable position,” as it treats equally all establishments that meet the criteria laid down in the statutory and secondary legislation, irrespective of their form of ownership.
Grounds for the Ruling and Disposition
Pursuant to Article 149, paragraph 1, item 2 of the Constitution (empowering the Court to rule on requests for the establishment of the unconstitutionality of laws and other acts of the National Assembly), the Constitutional Court rejects the request of a three-member panel of the Third Division of the Supreme Administrative Court, First Chamber, for a declaration of unconstitutionality of the provisions of Article 55, paragraph 2, items 3b and 3c of the Health Insurance Act (promulgated in the State Gazette, Issue No. 70 of 1998, last amended and supplemented, State Gazette, Issue No. 64 of 2025).
The decision is adopted with one dissenting opinion and one separate opinion.