Judgment;Summary — ECLI:EU:C:2020:745
Date: 2020-09-23
Language of the case: Hungarian
Court formation: Fourth Chamber
Subject matter: Freedom to provide services;Social security for migrant workers;Free movement of workers
Procedure: Reference for a preliminary ruling
Origin: Hungary

Summary C-777/18 - 1 
Case C-777/18 
Summary of the request for a preliminary ruling pursuant to Article 98(1) of 
the Rules of Procedure of the Court of Justice 
Date lodged: 
11 December 2018 
Referring court:  
Szombathelyi Közigazgatási és Munkaügyi Bíróság (Szombathely 
Administrative and Labour Court) (Hungary) 
Date of the decision to refer: 
28 November 2018 
Applicant:  
WO 
Defendant:  
Vas Megyei Kormányhivatal (Government Delegation in the Vas 
county, Hungary) 
      
Subject-matter of the main proceedings 
Dispute between WO and the Vas Megyei Kormányhivatal (Government 
Delegation in the Vas county) concerning the rejection of a request for 
reimbursement of the costs of healthcare (glaucoma surgery) provided in another 
EU Member State (Germany).  
Subject-matter and legal basis of the request for a preliminary ruling 
Interpretation of the following articles: 
Article 56 TFEU. 
Articles 8(1) and 9(3) of Directive 2011/24/EU of the European Parliament and of 
the Council of 9 March 2011 on the application of patients’ rights in cross-border 
healthcare. 
EN 
SUMMARY OF THE REQUEST FOR A PRELIMINARY RULING — CASE C-777/18 
 
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Article 20(1) of Regulation (EC) No 883/2004 of the European Parliament and of 
the Council of 29 April 2004 on the coordination of social security systems. 
Article 26(1) and (3) of Regulation (EC) No 987/2009 of the European Parliament 
and of the Council of 16 September 2009 laying down the procedure for 
implementing Regulation (EC) No 883/2004 on the coordination of social security 
systems. 
Legal basis: Article 267 TFEU 
Questions referred for a preliminary ruling 
(1) Does national legislation, such as that at issue in the main proceedings, 
which, as regards the reimbursement of the costs of cross-border healthcare, 
precludes the healthcare provided in another Member State without prior 
authorisation from being subsequently authorised, even when there is a 
genuine risk that the patient’s state of health may irreversibly deteriorate 
while waiting for that prior authorisation, amount to a restriction contrary to 
Article 56 of the Treaty on the Functioning of the European Union (TFEU)? 
(2) Does a Member State’s authorisation system which, as regards the 
reimbursement of the costs of cross-border healthcare, precludes subsequent 
authorisation, even when there is a genuine risk that the patient’s state of 
health will irreversibly deteriorate while waiting for prior authorisation, 
comply with the principles of necessity and proportionality set out in Article 
8(1) of Directive 2011/24/EU of the European Parliament and of the Council 
of 9 March 2011 on the application of patients’ rights in cross-border 
healthcare and with the principle of the free movement of patients?  
(3) Does national legislation which, regardless of the state of health of the 
patient submitting the request, establishes a procedural time limit of 31 days 
within which the competent authority may grant prior authorisation and of 
23 days within which it may refuse authorisation, comply with the 
requirement to set a reasonable procedural period taking into account 
specific medical conditions, urgency and individual circumstances, laid 
down in Article 9(3) of Directive 2011/24/EU of the European Parliament 
and of the Council of 9 March 2011 on the application of patients’ rights in 
cross-border healthcare? The authority may assess, in respect of the request, 
whether the provision of healthcare is covered by social security and, if so, 
whether it may be delivered, within a time limit that is medically justifiable, 
by a publicly-funded healthcare provider, whereas if it is not covered by 
social security, the authority assesses the quality, safety and cost 
effectiveness of the healthcare delivered by the provider indicated by the 
patient. 
(4) Must Article 20(1) of Regulation (EC) No 883/2004 of the European 
Parliament and of the Council of 29 April 2004 on the coordination of social 
VAS MEGYEI KORMÁNYHIVATAL 
 
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security systems be interpreted as meaning that the reimbursement of cross-
border healthcare costs may only be requested if the patient has applied for 
prior authorisation to the competent authority? Or does Article 20(1) not in 
itself in such a case preclude applying for subsequent authorisation for 
reimbursement of the costs? 
(5) Does the situation where a patient travels to another Member State having 
obtained a specific appointment for a medical examination and a provisional 
appointment for possible surgery or medical intervention on the day 
following the examination and, given the state of the patient’s health, the 
surgery or intervention is actually performed, come within the scope of 
Article 20(1) of Regulation (EC) No 883/2004 of the European Parliament 
and of the Council of 29 April 2004 on the coordination of social security 
systems? Is it possible, in that case, to apply for subsequent authorisation for 
reimbursement of the costs under Article 20(1)? 
(6) Is the situation where a patient travels to another Member State having 
obtained a specific appointment for a medical examination and a provisional 
appointment for possible surgery or medical intervention on the day 
following the examination and, given the state of the patient’s health, the 
surgery or intervention is actually performed, covered by the concept of 
scheduled treatment within the meaning of Article 26 of Regulation (EC) No 
987/2009 of the European Parliament and of the Council of 16 September 
2009 laying down the procedure for implementing Regulation (EC) No 
883/2004 on the coordination of social security systems? If so, is it possible, 
under Article 26, to apply for subsequent authorisation for reimbursement of 
the costs? In the case of an urgent vitally necessary treatment, referred to in 
Article 26(3), does the regulation also require prior authorisation in terms of 
Article 26(1)?  
Provisions of European Union law relied on 
– Article 56 TFEU. 
– Articles 8(1) and 9(3) of Directive 2011/24/EU of the European Parliament and 
of the Council. 
– Article 20(1) and (2) of Regulation (EC) No 883/2004. 
– Article 26(1) and (3) of Regulation (EC) No 987/2009. 
– Judgment of the Court of Justice of 5 October 2010, Elchinov (C-173/09, 
EU:C:2010:581). 
SUMMARY OF THE REQUEST FOR A PRELIMINARY RULING — CASE C-777/18 
 
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Provisions of national law relied on 
Paragraph 27(6) of the a kötelező egészségbiztosítás ellátásairól szóló 1997. évi 
LXXXIII. Törvény (Law LXXXIII of 1997, on the provision of compulsory 
sickness insurance) confers on insured persons the right to reimbursement of the 
costs related to healthcare provided abroad. The organisation providing sickness 
insurance must reimburse costs related to those services in the same amount that it 
would have reimbursed if the insured person had been cared for by a Hungarian 
healthcare provider which has entered into an agreement with the organisation 
providing sickness insurance. However, the costs of treatments listed in specific 
legislation are only to be reimbursed if the insured person has obtained prior 
authorisation, as well as a medical prescription if it is needed in the national 
territory to receive those treatments. 
A külföldön történő gyógykezelések részletes szabályairól szóló 340/2013. (IX. 
25.) Korm. Rendelet (Governmental Decree No 340 of 25 September 2013 
establishing detailed rules regarding medical treatments abroad): 
– Article 2(1)(a) sets out the general rule that, as regards medical treatments 
abroad, the EU Regulation on the coordination of social security systems 
(Regulation No 883/04) is primarily applicable. 
– Article 3(1) states that the Nemzeti Egészségbiztosítási Alapkezelő (National 
Health Insurance Fund) (‘the NEAK’) is to issue the documents necessary to 
receive medical treatment abroad. 
– Article 5(1) to (6) contains the procedural rules for the grant of prior 
authorisation. In that procedure, the NEAK determines whether the treatment at 
issue may be provided, within a time limit that is medically justifiable, by a 
Hungarian healthcare provider in the context of sickness insurance. Before 
granting the authorisation, the NEAK examines the quality and safety of the 
medical treatment offered by the chosen foreign provider, as well as the cost 
effectiveness of the service provided abroad. If the NEAK authorises treatment 
abroad, it issues, within 31 days from the submission of the application, a 
document which allows the treatment in accordance with Regulation No 
883/04. 
Succinct presentation of the facts and procedure in the main proceedings 
1 The applicant, a Hungarian national, cannot see out of his left eye due to a 
previous retinal detachment, and, in 2015, was diagnosed with glaucoma in his 
right eye. He received treatment in a number of Hungarian health institutions, 
where he was prescribed different eye-washes. The eye-washes were ineffective, 
the applicant’s visual field continued to decrease and his eye pressure was high 
(37 mmHg on 15 October 2016, compared with the highest admissible value of 21 
mmHg). In those circumstances, the applicant contacted a doctor from the 
Aurelios Augenzentrum in the German city of Recklinghausen, who set an 
VAS MEGYEI KORMÁNYHIVATAL 
 
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appointment on 17 October 2016 for a medical examination and a provisional 
appointment on 18 October 2016 for possible surgery. After the examination, the 
doctor decided to carry out the surgery the next day, considering it urgent in order 
to prevent the patient from becoming blind. On 18 October 2016, the surgery was 
carried out satisfactorily. 
2 Then, the applicant submitted a request to the defendant for reimbursement of the 
costs related to cross-border healthcare. The defendant refused the request. 
3 The applicant appealed to the second-tier authority [Budapest Főváros 
Kormányhivatala (Government Delegation in the capital Budapest)], which 
upheld the [defendant’s] decision refusing the request, on the ground that the eye 
surgery abroad had been a scheduled operation. Had the treatment received prior 
authorisation, the costs would have been admissible. The applicant brought an 
administrative-law action against that second-tier decision. 
The essential arguments of the parties in the main proceedings 
4 The applicant requests reimbursement of the costs of medical treatment abroad 
and disputes the second-tier decision insofar as it upholds the decision refusing 
that request. 
5 The defendant contends that the action should be dismissed and its decision 
upheld. In the grounds of that decision, it observed that the eye surgery abroad 
was scheduled surgery and that the applicant had not obtained prior authorisation 
for the treatment, which would have rendered the costs admissible. In those 
grounds, the defendant relied on Paragraph 27(6) of Law LXXXIII of 1997, 
Articles 4, 19, 20 and 27 of Regulation No 883/2004, Articles 25 and 26 of 
Regulation No 987/2009 and Articles 3(1) and 4(1) of Governmental Decree No 
340 of 25 September 2013. 
Succinct presentation of the reasoning in the request for a preliminary ruling 
6 The referring court points out, referring to the judgment in Elchinov (C-173-09), 
that Article 56 TFEU (formerly Article 49 EC) and Regulation No 883/04 
(formerly Regulation No 1408/71) preclude legislation of a Member State which 
excludes, in all cases, reimbursement in respect of the costs of hospital treatment 
given in another Member State without prior authorisation. 
7 Regulations No 883/04 and No 987/09 do not preclude either the granting of or 
the application for authorisation ex post facto or after the event (‘subsequent 
authorisation’). The Hungarian legislation precludes, however, the possibility of 
granting subsequent authorisation, which interferes with the freedom to provide 
services, given that the patient, depending on his state of health, is not always able 
to apply for prior authorisation for treatment abroad, if there is a risk that his 
health would deteriorate owing to that authorisation procedure. Nonetheless, in 
SUMMARY OF THE REQUEST FOR A PRELIMINARY RULING — CASE C-777/18 
 
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that system, an application submitted ex post facto is unequivocally dismissed. 
That may discourage the patient from having recourse to medical treatment in 
another Member State. 
8 The Hungarian legislation does not comply with the requirement of necessity and 
proportionality enshrined in Article 8(1) of Directive 2011/24, because it 
precludes the possibility of applying for subsequent authorisation even in specific 
situations linked to the patient’s state of health (for example, urgent vitally 
necessary treatment). In fact, the referring court finds that the possibility provided 
in that directive of establishing a prior authorisation system does not mean that 
subsequent authorisation is precluded. 
9 The Hungarian legislation is also contrary to Article 9(3) of Directive 2011/24, 
because it only sets out the authorisation procedure and the corresponding time 
limits, but does not provide for any special circumstances which may arise. In the 
referring court’s view, the fact that that procedure does not take into account 
exceptional circumstances which require shorter time limits constitutes an 
obstacle in obtaining prior authorisation and, consequently, may discourage some 
patients from applying for that authorisation. 
10 Furthermore, the referring court doubts whether Regulations 883/04 and 987/09 
preclude the granting of subsequent authorisation in the event that, after carrying 
out a medical examination in another Member State, surgery on the next day is 
deemed necessary, even when the provider in the other Member State has 
previously set the date of the possible surgery.