ECJ rules that treatment outside the EU must be reimbursed

The European Court of Justice has ruled that medically necessary treatment outside the EU must be reimbursed for the holders of valid E111 and E 112 forms.

The ECJ judgement addressed the situation of Annette Keller, a German national resident in Spain who arranged for a 1 month E111 form to cover a trip back to her home country. During that period, she was diagnosed with a malignant tumour and required medical treatment. Ms Keller requested and was issued with an E112 (extended several times) Spanish health system issued her with an E112 form to cover the costs of her treatment in Germany.

The doctors treating Ms Keller decided that she needed care at a specialist clinic in Switzerland and she was consequently underwent an operation in Zurich. Ms Keller paid the €56 300 cost of the treatment and asked her Spanish health insurer to reimburse these expenses.

The insurer refused because they had not been consulted by the German doctors about the decision to seek treatment in Switzerland and said that they should have had the opportunity to provide alternative options.

Ms Keller died in 2001 and her family challenged the Spanish insurers in the national courts which referred the case to the ECJ.

The ECJ ruled on 12 April 2005 that the Spanish insurers should pay for the cost of the treatment.

The court stated that the doctors treating the patient are best placed to assess the treatment needed and that the health insurance structure of the home country places its confidence in the host country’s institutions, that the doctors have the same levels of professional competence as the home country. Therefore, the home country is bound by decisions of the doctors treating the patient. If the host country doctors decide to send the patient outside the EU for urgent treatment that they cannot provide, the home country insurance must accept their judgement and pay for the treatment.

The ECJ also re-stated the principle that in the case of a decision to send the patient outside the EU for treatment, it is the host country (e.g Germany) that would cover the cost of treatment in the same way that it pays for its own citizens. Afterwards, the host country is reimbursed by the home country, in this case Spain.

Since Ms Keller had paid for the treatment in Switzerland herself, the ECJ ordered the Spanish health insurance to reimburse her family.

This is the latest in a series of court rulings on reimbursement of medical costs for patients who have been treated in other EU countries.

See related EPHA article.

ECJ Press release on the judgement.