Judgment;Summary — ECLI:EU:C:2022:924
Date: 2022-11-24
Language of the case: Hungarian
Court formation: Eighth Chamber
Subject matter: Taxation;Value added tax
Procedure: Reference for a preliminary ruling
Origin: Hungary

Translation C-458/21 – 1 
Case C-458/21 
Request for a preliminary ruling 
Date lodged: 
22 July 2021 
Referring court: 
Kúria (Hungary) 
Date of the decision to refer: 
17 June 2021 
Appellant: 
CIG Pannónia Életbiztosító Nyrt. 
Respondent: 
Nemzeti Adó- és Vámhivatal Fellebbviteli Igazgatósága  
  
KÚRIA (SUPREME COURT) 
[…] 
Decision 
[…] 
Subject matter of the proceedings: Administrative-law appeal in tax matters. 
Appellant: the defendant at first instance 
Cross-appellant: the applicant at first instance 
[…] 
Operative part 
The Kúria (Supreme Court) […] is making a reference to the Court of Justice of 
the European Union for a preliminary ruling pursuant to point (b) of [the first 
paragraph of] Article 267 of the Treaty on the Functioning of the European Union, 
EN 
REQUEST FOR A PRELIMINARY RULING OF 17. 6. 2021 – CASE C-458/21 
 
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concerning the interpretation of Article 132(1)(c) of Council Directive 
2006/112/EC [of 28 November 2006 on the common system of value added tax]. 
The Supreme Court asks the Court of Justice to give a preliminary ruling on the 
following question: 
Must Article 132(1)(c) of [Council] Directive 2006/112/EC [of 
28 November 2006 on the common system of value added tax] be 
interpreted as meaning that a service used by [an insurance company] is 
exempt from VAT where the purpose of the service is: 
– to verify the accuracy of a diagnosis of a serious illness with which the 
insured has been diagnosed; and 
– to seek the best medical care available to treat the insured; and 
– where included in the cover offered by the insurance policy and at the 
request of the insured, to arrange provision of the medical care abroad? 
[…] [procedural aspect of national law] 
Reasoning 
Facts of the main proceedings 
1. Since September 2012, the appellant insurance company has marketed a 
series of health insurance and life assurance products in which it undertakes 
to guarantee provision of medical care abroad, in certain circumstances, 
where the insured is suffering from any of the following five serious 
conditions: cancer, by-pass surgery, heart valve problems, neurosurgery and 
living donor organ and tissue transplants. The document entitled Best 
Doctors® Health Insurance Special Policy Conditions (‘the Special 
Conditions’) contains rules defining the specific conditions of the insurance 
policy. According to point 4(a) of the Special Conditions, use of 
InterConsultation (or ‘a second medical opinion’, as it is referred to in the 
Special Conditions; ‘IC’) is a precondition for obtaining medical care 
abroad. FindBestCare (‘FBC’) is part of the medical care provided abroad. 
Point 2(p) of the Special Conditions contains the description of IC, 
point 2(m) of the document contains the definition of FBC, and point 13 
describes the stages of the procedure for requesting cover. 
2. To enable it to provide the policy benefits, on 13 September 2012 the 
appellant entered into a cooperation agreement (‘the cooperation 
agreement’) with Best Doctors España, S. A. U. (‘the Spanish company’), 
which is the Spanish member of the Best Doctors® international business 
group, for use of the patented medical information service. Under that 
CIG PANNÓNIA ÉLETBIZTOSÍTÓ 
 
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agreement, what are termed the ‘Best Doctors Services’ comprise two 
elements: IC and FBC. Under IC, based on the documentation sent to them, 
doctors for Best Doctors® re-examine the insured’s medical information in 
order to confirm that the insured is entitled to the policy benefits. Under the 
agreement, the benefits do not apply in cases of acute illness or where the 
illness has yet to be examined by a ‘local’ healthcare professional. Under the 
FBC service, where the insured’s policy provides this cover, the Spanish 
company arranges an appointment with the medical service providers on 
behalf of the insured, organises the medical treatment (admission and 
appointments), hotel accommodation and travel, ensures that care is 
provided and checks that the medical treatment is appropriate. It also deals 
with processing and paying medical fees in accordance with the contracts 
with the medical service providers. It does not bear the travel and 
accommodation costs or the costs of the medical care provided. FBC cannot 
be used for care provided in Hungary (cooperation agreement, Schedule ‘A’, 
points 1 and 2). 
3. Under the cooperation agreement, the appellant pays an annual premium for 
the Best Doctors Services for each person insured, making payments with 
the same frequency as the premium payments made by the insured persons 
to the appellant (cooperation agreement, point ‘E’). 
4. During the period from October to December 2012, the Spanish company 
issued three invoices for payment for services, on which the appellant did 
not pay value added tax (VAT). 
5. During the period to which the proceedings refer, the appellant had not yet 
made use of the Best Doctors® service provided by the Spanish company, 
but it was still required to pay the premiums, and did so. 
6. By decision of 5 May 2016 […], made following an inspection carried out 
by the Nemzeti Adó- és Vámhivatal Kiemelt Adó- és Vámigazgatósága 
(National Tax and Customs Authority, Hungary; […]) on the appellant, as 
the group’s tax representative, to provide an a posteriori check on the VAT 
returns for the period from 1 May to 31 December 2012, the appellant was 
ordered to pay a difference in tax of HUF 1 059 000, a tax fine of 
HUF 529 000, late payment interest of HUF 178 000 and a fine for breach of 
tax obligations of HUF 20 000. 
7. By decision of 14 November 2016 […], the respondent, which heard the 
appeal lodged against the decision made at first instance, partially amended 
that decision, reducing the amount of the tax fine to HUF 376 000, and 
confirmed all other elements of [the decision under appeal]. 
8. The respondent based its decision on Article 132(1)(c) of Council Directive 
2006/112/EC of 28 November 2006 on the common system of value added 
tax (‘the VAT Directive’); Article 37(1), Article 60(1) and (2), Article 65, 
REQUEST FOR A PRELIMINARY RULING OF 17. 6. 2021 – CASE C-458/21 
 
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Article 82(1), Article 85(1)(c). Article 120(b) and Article 140(a) of the az 
általános forgalmi adóról szóló 2007. évi CXXVII. törvény (Law CXXVII 
of 2007 on value added tax, ‘the VAT Law’); and the judgments of the 
Court of Justice of the European Union in D., C-384/98; Kügler, C-141/00; 
and d’Ambrumenil and Dispute Resolution Services, C-307/01. 
9. According to paragraph 2 of the grounds, with which the proceedings are 
concerned, the service provided to the appellant by the Spanish company 
does not satisfy the requirements for exemption from value added tax in 
Article 85(1)(c) of the VAT Law, since the fees in the three invoices 
constitute a form of flat rate that did not directly reflect actual provision of 
healthcare, diagnostic treatment or curative services to the individual. The 
purpose of the re-examination of the prior medical documentation during the 
IC service is to confirm whether the insured is entitled to receive medical 
care abroad, for which the second medical opinion is a prerequisite. The 
Spanish [company] does not perform examinations in order to arrive at a 
diagnosis, and it does not provide medical treatment; instead, based on the 
prior medical documentation, it judges and assesses the results of such 
examinations and treatments in order to determine whether the risk insured 
by the client’s policy has occurred. The Spanish company examines, 
assesses, and at times organises medical care, but it does not provide care, 
nor does it treat or cure illnesses or health disorders, and the services ― 
whether considered collectively or individually ― cannot be classed as 
medical treatment. Having regard to the main purpose of the financial 
transaction recorded in the invoices, the services provided cannot be classed 
as human health services exempt from VAT, but are essentially expert 
opinions and organisational activities, and therefore the appellant must pay 
VAT of HUF 752 000. 
10. In its administrative-law appeal against the decision of the tax authority, the 
appellant maintained that the authority had wrongly classified the services 
received from the Spanish company, because Best Doctors® not only 
assesses the medical documents but also performs supplementary 
examinations (for example, a histological analysis of the tissue samples sent 
to it), and its services also include seeking out the best foreign medical 
specialists and obtaining their opinion; the purpose of their services is 
therefore to treat the patient and ensure that the patient receives the most 
effective therapy possible. The IC is not an administrative requirement but 
an essential element of the service that forms part of its insurance benefits, 
in the context of which the doctor or medical team preparing the report 
performs a diagnosis. The most valuable element of the service provided by 
Best Doctors® is the diagnosis of health disorders and illnesses, which 
satisfies the concept of medical care in Article 132(1)(c) of the VAT 
Directive and is therefore exempt from VAT. 
11. The court of first instance partially upheld the appeal brought by the 
appellant and ordered the tax authority to carry out new proceedings. Based 
CIG PANNÓNIA ÉLETBIZTOSÍTÓ 
 
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on the opinion of the forensic medical expert, which took into account the 
medical reports prepared and supplied by Best Doctors® at the end of the 
period under inspection, the court concluded that the purpose of the IC 
service provided as part of Best Doctors® is directly, unequivocally, and 
also in practice, not only to provide people with healthcare, but also to 
improve their health and to diagnose and treat illnesses. It also considered 
that the agreements and the Special Conditions did not support the tax 
authority’s conclusions that the main purpose of the IC was to prepare an 
expert opinion in order to determine whether the insured was entitled to 
subsequent insurance benefits. The court of first instance ordered the tax 
authority to carry out additional checks as part of the new proceedings. 
12. Both parties lodged appeals with the Supreme Court against the judgment 
given at first instance. 
13. Citing the judgment of the Court of Justice in Unterpertinger, C-212/01, in 
its appeal the respondent argues that the Best Doctors® services are only 
indirectly linked to the therapeutic purpose, and therefore cannot be 
considered to be exempt from VAT. It maintains that the Spanish company 
did not diagnose individuals or care for them, and did not give them medical 
treatment or healthcare. 
14. In its cross-appeal, the appellant maintains that the assessment of the 
evidence made by the court of first instance was not reasonable since, based 
on that evidence and having regard also to the judgments of the Court of 
Justice in Verigen Transplantation Service International, C-156/09, and 
CopyGene, C-262/08, the questions contained in the instructions for the new 
proceedings can be answered as follows: 
(i) the expert evidence presented to the court confirms that the purpose of 
the IC is directly and unequivocally to perform a diagnosis; in other 
words, it has a therapeutic purpose and therefore satisfies the material 
requirement for human health services exempt from VAT; 
(ii) from an interpretation of the cooperation agreement and the Special 
Conditions, together with the accompanying schedules, it is possible to 
identify the content of the legal relationship, under which Best 
Doctors® offers the insured the IC service as a policy benefit, while 
the FBC is provided after the diagnosis, as an optional element 
ancillary to the diagnosis, and a standard tariff is charged for the Best 
Doctors® services; 
(iii) the information and data supplied by the appellant clearly show that 
the IC service is the defining element of the insurance service and, 
while the FBC is part of the service, its nature is purely ancillary. It 
can clearly be concluded from all of the foregoing that the IC is an 
essential element of the complex service provided by Best Doctors® 
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and directly and unequivocally fulfils a therapeutic purpose, and it 
therefore satisfies the requirements for human health services exempt 
from VAT. No further evidence is required by the tax authority. 
15. Relevant provisions of EU law 
Council Directive 2006/112/EC of 28 November 2006 on the common system 
of value added tax (VAT Directive) 
CHAPTER 2 
Exemptions for certain activities in the public interest 
Article 132 
1. Member States shall exempt the following transactions: 
(a) the supply by the public postal services of services other than passenger 
transport and telecommunications services, and the supply of goods incidental 
thereto; 
(b) hospital and medical care and closely related activities undertaken by bodies 
governed by public law or, under social conditions comparable with those 
applicable to bodies governed by public law, by hospitals, centres for medical 
treatment or diagnosis and other duly recognised establishments of a similar 
nature; 
(c) the provision of medical care in the exercise of the medical and paramedical 
professions as defined by the Member State concerned; 
16. Relevant provisions of national law 
2007. évi CXXVII. törvény – az általános forgalmi adóról (Law CXXVII of 
2007 on value added tax) 
CHAPTER VI 
EXEMPTION FROM VAT 
Exemption from VAT on grounds of the public interest nature of the activity 
Article 85(1) 
The following shall be exempt from VAT: 
[…] [provision not relevant to the case] 
CIG PANNÓNIA ÉLETBIZTOSÍTÓ 
 
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(b) medical care, closely related care and transport services for the sick and 
wounded, and the supply of goods closely linked to such services, provided by 
public operators, acting as such; 
(c) services provided by healthcare providers, including naturopathy providers, 
acting as such, and care of the sick and wounded closely related to such services; 
Proceedings before the Supreme Court 
17. In the appeals brought by the parties, the Supreme Court must decide 
whether the service the Spanish company provides to the appellant is a 
service exempt from VAT pursuant to Article 132(1)(c) of the VAT 
Directive. 
18. According to the case-law of the Court of Justice, the VAT Directive (and 
the Sixth Directive, previously in force) confers a very wide scope on VAT, 
but exempts certain activities from the tax. These exemptions constitute 
independent concepts of EU law whose purpose is to avoid divergences in 
the application of the VAT system as between one Member State and 
another. The purpose of these VAT exemptions is to exempt only those 
public interest activities listed and described in detail in the Directive. The 
terms used to specify those exemptions are to be interpreted strictly, since 
they constitute exceptions to the general principle that VAT is to be levied 
on all goods and services supplied for consideration by a taxable person. 
Nevertheless, the interpretation of those terms must be consistent with the 
objectives pursued by the exemptions and comply with the requirements of 
the principle of fiscal neutrality inherent in the common system of VAT, 
while also ensuring that the provisions on VAT exemptions can have effect. 
19. It can be seen from the case-law of the Court of Justice of the European 
Union that Article 132(1)(b) of the VAT Directive [or Article 13A(1)(b) of 
the Sixth Directive, previously in force] refers to medical treatment provided 
as part of hospital care, while point (c) of the provision is concerned with 
healthcare provided outside that context, whether at the provider’s private 
premises, the patient’s home, or anywhere else. The concept of ‘the 
provision of medical care’ referred to in Article 132(1)(c) of the VAT 
Directive also relates to services which have as their purpose the diagnosis, 
treatment and, in so far as possible, cure of diseases or health disorders; 
however, it does not necessarily follow, according to the case-law, that the 
therapeutic purpose of a service must be confined within a particularly 
narrow compass. 
20. According to the case-law, medical examinations of individuals for 
employers or insurance companies, the taking of blood or other bodily 
samples to test for the presence of viruses, infections or other diseases on 
behalf of employers or insurers, or certification of medical fitness, for 
example, as to fitness to travel, are exempt from VAT where those services 
REQUEST FOR A PRELIMINARY RULING OF 17. 6. 2021 – CASE C-458/21 
 
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are intended principally to protect the health of the person concerned 
(d’Ambrumenil and Dispute Resolution Services, C-307/01). The provision 
of care of a therapeutic nature by a capital company running an out-patient 
service under which care, including home care, is provided by qualified 
nursing staff (excluding the provision of general care and domestic help) is 
exempt from VAT (Kügler, C-141/00), as are services provided by 
telephone consisting of giving advice regarding health and illnesses, 
provided that they have a therapeutic purpose [X (VAT exemption for 
telephone consultations), C-48/19]. 
21. However, the Court of Justice of the European Union has ruled that the tax 
exemption does not apply to the preparation of medical reports or services 
provided by a doctor whose purpose is to examine whether a legal or 
contractual condition is satisfied, or which are required in order to assess 
claims that may be made by a particular individual in various proceedings 
(see, for example, Finanzamt D, C-657/19). The following are not exempt 
from VAT: giving certificates as to a person’s medical condition for 
purposes such as entitlement to a war pension (d’Ambrumenil and Dispute 
Resolution Services, C-307/01) or invalidity pension (Unterpertinger, 
C-212/01), or whose purpose is not closely related to medical care (for 
example, CopyGene, C-262/08 ― stem cell bank activities ― or PFC 
Clinic, C-91/12 ― plastic surgery and cosmetic treatments) or whose 
purpose is to determine liability and quantify damages for personal injury, or 
the preparation of medical opinions based on medical reports and 
examinations without conducting a medical examination, or [conducting] 
medical examinations with a view to the preparation of expert medical 
reports on professional negligence on the part of individuals involved in 
legal proceedings (d’Ambrumenil and Dispute Resolution Services, 
C-307/01). Nor are the following exempt: establishing the genetic affinity of 
individuals to certain diseases through biological tests (D., C-384/98) or 
nutrition monitoring services (Frenetikexito, C-581/19). 
22. In the case concerned in the present proceedings, the insured event is the 
serious illness of the insured, together with death and expiry of the policy. 
The liability borne by the insurance company (the appellant) comprises the 
medical care provided to the insured abroad and the organisational work 
required to obtain that care. The service which the appellant receives as a 
VAT-exempt service forms part of the insurance service it provides to the 
insured and, under the insurance policy, the ultimate objective of the service 
provided by the appellant is to enable the insured to receive medical care 
abroad organised by the Spanish company in the event of certain illnesses; 
ultimately, it serves to diagnose, treat and cure the insured’s illness. The 
service received by the insurance company forms part of this complex web 
of different contracts and therefore, in the opinion of the members of the 
Supreme Court hearing the case, these must be taken into consideration in 
deciding whether the service is exempt from VAT. 
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23. Considering that the medical care received under the policy also serves to 
diagnose, treat and, in so far as possible, cure health disorders, and having 
regard in general to the case-law of the Court of Justice ― Unterpertinger, 
C-212/01; Verigen Transplantation Service International, C-156/09; 
CopyGene, C-262/08; D., C-384/98; Kügler, C-141/00; d’Ambrumenil and 
Dispute Resolution Services, C-307/01; X (VAT exemption for telephone 
consultations), C-48/19; Peters, C-700/17; Belgisch Syndicaat van 
Chiropraxie and Others, C-597/17; Frenetikexito, C-581/19; Finanzamt D, 
C-657/19; … FC Clinic, C-91/12; Klinikum Dortmund, C-366/12; Solleveld 
and van den Hout-van Eijnsbergen, C-443/04 and C-444/04, and Future 
Health Technologies, C-86/09 ― the members of the Supreme Court 
hearing the case consider that a further interpretation of Article 132(1)(c) of 
the VAT Directive is needed in the context of the facts of the present case. 
24. […] [repetition of the question referred as set out in the operative part] 
25. […] [procedural aspect of national law] 
Budapest, 17 June 2021. 
[…] [signatures]