Ruling allows EU patients to be reimbursed for treatment outside the unionBMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7497.922-d (Published 21 April 2005) Cite this as: BMJ 2005;330:922
European Union patients who have received prior permission from their national health service or insurers to be treated in another EU country are entitled to have their costs covered even if they are subsequently given medical care outside the union, according to a new judgement from theEuropean Court of Justice. The ruling establishes the principle that health authorities in one member state are bound by decisions that may be taken by those in another.
The case revolved around Annette Keller, a German citizen living in Spain. In October 1994, she received an E111 form, valid for one month, from the Spanish national health service, InstitutoNacional de la Salud (Insalud), which entitled her to any immediate treatment she might require when visiting her native country.
In Germany, she was diagnosed as having a malignant tumour which could cause her death at any time. She then contacted the Spanish authorities, who provided her with an E112 form. This authorises a patient to go to another EU country to receive appropriate medical treatment.
After careful examination, the German doctors, without consulting the Spanish health system, decided that the only hospital which could treat Ms Keller's condition with recognised scientific efficacy was the private Zurich University Clinic in Switzerland.
They sent Ms Keller to Switzerland, where she was treated. She paid for the costs of her medical care SFr87 030 (£38 500; $73 300; €56 300) herself. When she tried to be reimbursed, her health insurer, Insalud, refused, arguing that she needed prior authorisation before being treated in a non-EU country. It also maintained that it should have had the opportunity to propose alternative care and to decide if her condition was life threatening.
Faced with their refusal, Ms Keller opened legal proceedings in Spain. Although she died in October 2001, her family continued the action which was eventually referred to the EU's highest court in Luxembourg.
In their ruling, the judges noted that all the formalities in the E111 and E112 procedures hadbeen fully complied with. These ensure that a patient is entitled to receive the same care as citizens of the member state of stay (in this case Germany) and that the costs will be borne by the member state of affiliation (Spain) during the period of validity of the forms.
They also concluded that the doctors in the member state of stay are best placed to assess thetreatment a patient requires. If they decide it is urgent and can only be provided by another country, the original health insurer must cover the costs. The judges noted that the principle stillapplied even if the patient was transferred to a non-EU country. The European Court of Justice ordered the Spanish social security authorities to reimburse the cost of Ms Keller's treatment to her heirs.
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