To be reimbursed for treatment provided in the European Union, prior authorization from Health Insurance is required. Between 2002 and 2006, the Sécu rejected nearly one in two cases.
The Court of Appeal of the Versailles court has just rendered a decision which health insurance would have gone well. In October, she authorized a French woman who, since 1999, has been asking for authorization to take care of herself in Germany and to be reimbursed. This 44-year-old suffers from a celiac disease, diagnosed in 1986. The violent and chronic pain inherent in this pathology led her to several pain management services. Unfortunately, no treatment has been effective. From sick leave, to acute crises, his ordeal continues. So much so that a severe nephrotic syndrome required psychiatric follow-up with hospitalization on several occasions.
These failures pushed him to see what was practiced outside our borders. And through the media, in 1999 she learned of the existence of a pain treatment center in Germany, capable of providing her with appropriate care. The patient immediately requested authorization from her primary health insurance fund (CPAM). In fact, to be reimbursed for treatment provided abroad, prior authorization from the health insurance is necessary. But the CPAM refused on the pretext that pain management services exist in France. A refusal which is not isolated since between 2002 and 2006 in France, 43% of requests for care in the European Union were not accepted. This high rate is due in particular to numerous requests for medically assisted procreation acts that do not comply with French regulations.
The patient did not give up, after numerous appeals before French institutions, she appealed to the Court of Justice of the European Communities. Doesn’t this prior authorization demanded by Health Insurance contradict the principles of freedom on which the European Union is founded (freedom of movement, freedom of services)? “Without calling into question this authorization, the European Court replied on October 23, 2003, that we could not refuse to reimburse treatment that is identical or has the same degree of effectiveness for the patient”, explains Corinne Daver, lawyer. of the complainant, specializing in health issues at the Fidal cabinet. With this case law, the Versailles Court of Appeal therefore quashed the refusal of the Primary Health Insurance Fund. This lady will be able to go to Germany and be reimbursed for the care on the basis of the rates applied in France. In addition, she will receive damages from the CPAM.
This example shows that the European health sector is no longer limited to the E111 forms, a paper replaced since 2006 by the European health insurance card (valid in 31 countries, the Member States of the Union plus Switzerland, Iceland and Norway), delivered to 4.2 million copies in France in 2005.
Even if the coordination of the social security systems of the Member States is established on two regulations dating from the 1970s (1), this case also illustrates that the Europe of health is mainly done on the initiative of its citizens and its professionals. health. While this is a first in France, precedents have already taken place in Luxembourg and the Netherlands. The Kohll and Decker judgments in 1998 taken by the Court of Justice of the European Communities have already broken the monopoly of Social Security, by establishing for the first time the principle of the free movement of goods and the provision of health services within of the Union. Mr Decker, from Luxembourg, was reimbursed for glasses he had bought from a Belgian optician. In July 2001, the Court of Justice went even further with the Smits-Peerbooms and Vanbrackel judgments concerning the reimbursement of hospital services. Ms Smits-Garets, Dutch, requested reimbursement from her insurance fund for costs incurred in Germany for the treatment of Parkinson’s disease, which she felt she could not obtain in the Netherlands.
These cases remain exceptions. A survey, carried out by the CSA institute, shows that 40% of French people are ready to seek abroad “a superior medical technique and not available in their country”. The European Commission estimates that care provided outside their country of insurance corresponds to only 1% of all public health expenditure. These estimates naturally remain to be approached with caution given the weakness of the statistical apparatus.
But for those who live in border departments, this is not anecdotal. There are cross-border cooperation. First example in Cerdagne, particular case of an isolated valley straddling the Franco-Spanish border, population basin of 28,000 inhabitants more than 100 km from Perpignan via the Col de Perxa and 140 km from Barcelona via the tunnel du Cadi. The French Cerdanya does not have a hospital, and on the Spanish side, there is that of Puigicerda. An agreement between the French funds and the Puigicerda hospital allows the French to be reimbursed for the care provided in this hospital. And since April 2002, the hospitals of Saint-Jean-de-Perpignan and that of Puigicerda have signed a collaboration agreement. Same type of example at the Franco-Italian border.
France attracts foreign patients
Likewise, can an Alsatian choose a German doctor as an attending physician, or a Lille resident a Belgian doctor? A circular from the Ministry of Health has authorized it since May 2005. “Due to the freedom to provide services in the European Union, the choice of appointing an attending physician established outside France is left to French policyholders”. On condition that the doctor in question practices legally and accepts. At the National Health Insurance Fund, we recognize that a handful of French policyholders have chosen a European doctor. But their census, held by the CPAMs, has not yet gone back to the National Fund …
It is still not clear when it comes to assessing the number of treatments carried out abroad reimbursed by health insurance. Between the CNAM, the ministry and the Center for European and International Social Security Connections (CLEISS), we refer back to the accounts… According to CLEISS, in 2005, healthcare reimbursements represented 250 million euros for nationals affiliated to French social security schemes which have received treatment in other Member States. For its part, the CNAM explains that it reimbursed 590,000 invoices for care provided to French policyholders around the world in 2006, which represents a total amount of 42 million euros. But the distinction is not made between the care consumed during a tourist stay, for French residents living abroad, or for French people who have left to seek treatment in the European Union. For the CNAM, this amount remains minimal compared to the overall amount of care and products reimbursed in France. Certainly, but some predict an increase in demand. For Christian Saout, president of a group of user associations, “with the economic pressure on households, the temptation to seek treatment elsewhere at a lower cost will increase, especially in the new member countries of the Union. … This temptation can be all the greater since in certain cases the value for money is not clearly displayed in France. “
However, the movement of patients will not only be from France to other countries. As Senator Roland Ries noted in a report in 2007, “France imports more foreign patients than it exports French patients”. Thus, 518,000 people coming from social security funds in other Member States were treated in France in 2005. We remember that the English were attracted by the services provided by French hospitals, in particular at the CHRU in Lille. “The Lille experience of welcoming British patients in this regard was interesting but it failed because the technocratic Regional Hospitalization Agency did not want to give an additional authorization of beds for this activity, thus condemning this innovative initiative” , underlined the surgeon Jacques Meurette, ex-president of the Union of the surgeons of France, during a conference on globalization and health in 2006. And the surgeon Guy Vallancien noted that “countries like India, the Malaysia and Tunisia are becoming serious competitors of the best American and European centers for a price three to four times lower. Their elites were trained in the West and return to their country with a desire for surgical excellence ”.
(1) Regulation n ° 1408/71 relating to the application of social security schemes to salaried workers and their families who move within the Community, and Regulation n ° 574/72 laying down the modalities of application.
