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Are you in an EU State in which you would have to pay high co-payments as a person with statutory health insurance in order to receive medical benefits? Are you suffering from acute toothache, but the EU State in which you are temporarily staying has excluded dental treatment from its list of benefits? Do you need urgent medical assistance which you would like to receive from a healthcare provider who is not entitled to treat patients who are insured in the health insurance system of the State of stay?
In such cases, you can undergo private treatment. This means that you initially pay the invoice yourself and submit it to your German health insurance fund for a cost reimbursement.
You have caught the flu while studying in France, and receive medical treatment from a doctor in France. Since France has a cost reimbursement system, you would first of all have to pay the complete treatment costs in advance and would then receive a refund for 70 % of the treatment costs from the French healthcare insurer, the CPAM. You might be better off financially sending the invoice directly to your German health insurance fund and requesting a cost reimbursement according to the German rates.
Within the framework of the European Patient Mobility Directive, you can only take up treatment in another EU country where your German health insurance fund would also assume the costs for persons who have statutory health insurance in Germany.
According to this procedure, authorisation is also necessary if this would be the case under German law (e.g. for in-patient treatment, rehabilitation, prosthetic treatment, etc.). You will need to make sure that these conditions are also met under German law if you need to or would like to take up such a benefit in another EU country. Should you have any doubts, we recommend that you contact your health insurance fund or ourselves before undergoing treatment.
Your crown breaks during a holiday in Spain. Since dental treatment is not covered by the Spanish healthcare system, you visit a private dentist who provides you with emergency care and a temporary crown. One week later the Spanish dentist provides you with a new crown. You submit the invoice, which you have already paid, to your German health insurance fund once you have returned to Germany.
Please note that your German health insurance fund is only able to reimburse you for the cost of the emergency care and the temporary crown. It is not able to refund you for the crown proper since the German entitlement requirements were not met. These demand that a treatment and cost plan be submitted by the dentist in attendance before the prosthetic treatment is carried out, and that this be authorised by the German health insurance fund. You would only have received a refund for the prosthetic treatment if the dentist in Spain had sent the German treatment and cost plan to the German health insurance fund prior to treatment and it had been approved by the latter.
If the conditions are met for treatment the other EU-State, you can select a healthcare provider who is to carry out the treatment there. You are therefore not restricted to doctors and dentists who may only treat persons with statutory insurance.
If you have found a suitable healthcare provider, you conclude a treatment contract with him/her. This should contain information on the benefits to be provided and the costs involved.
Carefully keep all invoices issued by the healthcare providers during treatment. They absolutely must be submitted for a cost reimbursement. Make sure that the invoice clearly states exactly what was done and what it cost.
After the treatment, submit the itemised invoices issued in the respective Member State to your German health insurance fund for a reimbursement.
If you have not travelled to another EU country for treatment, and costs have only been incurred, for instance during a holiday, because treatment was not provided using the European Health Insurance Card, your health insurance fund will as a rule reimburse you at most the amount which it would have had to pay had the same treatment been provided in Germany, unless the documented contract rates would have been higher abroad. This means that co-payments which are provided for under German legislation or discounts on medicinal products which have been agreed are also included when calculating the amount of the reimbursement.
In the event of the health insurance fund also deducting a lump sum because no “value-for-money audit” can be carried out or because of higher administrative costs, you should notify your health insurance fund that you would like to receive a reimbursement on the basis of Article 25 § 6 of Regulation (EC) No 987/2009. The reimbursement will never be more than the cost which you actually incurred. The query form for the Standard Schedule of Fees (Einheitlicher Bewertungsmaßstab – EBM) provided by the National Association of Statutory Health Insurance Physicians can help you to gain an overall picture of any reimbursement amounts with regard to out-patient treatment should you have any doubts.
You have statutory health insurance in Germany. You unexpectedly had to undergo an operation when on holiday in Spain. The operation was carried out in a private clinic. Your health insurance fund in Germany would have had to pay 10,000 Euro for this treatment. Costs totalling 13,000 Euro were incurred in Spain.
Your health insurance fund will reimburse you a maximum of 10,000 Euro.
You can lodge an objection if your health insurance fund refuses to approve treatment that is planned in another EU country. The same applies if you consider the refund amount paid by your health insurance fund to be too low.
It is best for your objection to be made by letter or fax. It is important for your letter to reveal that you are not satisfied with the decision that has been taken. You can also visit your health insurance fund in person, where an official will take receipt of your objection. Please note that an objection sent by e-mail is not valid.
The objection should generally be filed with your health insurance fund within one month of your receiving the negative decision. This period is extended to three months if the decision was sent to you abroad. Please check to see if the negative decision that you have received from your health insurance fund indicates the possibility of lodging an objection. If this is not the case, you have one year in which to lodge a written objection.
It is recommended in your objection to inform the health insurance fund of the reasons why you are you are not satisfied with their decision. This is however not obligatory.
Once it has received your objection, the health insurance fund will examine the decision that it has taken. If it remains convinced that the decision that it took was correct, your objection will be forwarded to the “Objection Committee”. This committee is composed of representatives of insured parties and employers. The Objection Committee will then let you have a final written statement regarding whether or not it considers the decision taken by the health insurance fund to have been correct. You will also be informed at the end of the decision on the objection that you have the possibility to lodge an action with the Social Court that has jurisdiction within one month. The Social Court with jurisdiction is specified at the end of the Objection Committee’s ruling.
The period within which an action is to be lodged is once more extended to three months if the decision was sent to you abroad. The action can be sent to the court in writing. Since the action needs to meet certain requirements in terms of its content, it is recommended to lodge the action with the social court in person if you do not have legal counsel. In this case, the certifying official of the court registry records your action in writing and ensures that all the requirements in terms of its content are satisfied.
You do not have to have legal counsel in these “first instance” proceedings before the Social Court. This therefore means that you can engage in the proceedings without commissioning an attorney. The litigation before the social court also does not cost you anything.
If the court confirms the view taken by your health insurance fund, you will only have to meet your own expenses yourself. If however the Social Court upholds your view, your health insurance fund will have to pay the costs incurred by both you and by the court.
Treatment within the European Patient Mobility Directive generally offers greater scope with regard to the range of benefits available. However, it may be more expensive than treatment under the conditions for persons with statutory health insurance in the state of treatment. What is more, you will certainly have to pay the costs incurred yourself upfront. You should therefore seek detailed advice from your health insurance fund in Germany before undergoing treatment in the other state.