WRITTEN QUESTION P-1269/98

by Nikolaos Papakyriazis (PSE) to the Commission

(21 April 1998)

Subject: Financial cover for serious illnesses

Would you please tell me, on the basis of past practice, how the sickness insurance scheme deals financially with serious illnesses, for example bone cancer (100 % cover), when the treatment is administered in a non-member country such as Switzerland or the United States because of the particular nature of the case.

Have there been specific cases in the past of 100 % cover for cancer treatment in a non-member country? If so, would you please tell me:

- what countries were involved,

- what cover was provided and, if there were limits/ceilings on cover, on what basis they were applied and at what stage of the therapy,

- whether there was direct billing of the sickness insurance scheme,

- up to what level the costs of an accompanying person were accepted and reimbursed in the case of a minor or a seriously ill person,

- whether there were ceilings on payment in the case of:

1. emergency hospitalization

2. blood transfusion

3. intensive care in isolation

4. hospital treatment for immuno-deficiency,

- whether there were sliding scales based on a reference country for the calculation of reimbursements and, if so, which country and on what grounds.

If there is no information on any of the above questions because no actual cases have arisen to date, please reply on the basis of normal practice or the existing rules.

Answer given by Mr Liikanen on behalf of the Commission

(14 May 1998)

The Settlements Offices of the Joint Sickness Insurance Scheme apply the procedure set out as follows:

The medical expenses of a member suffering from an illness recognised as serious by the appointing authority are reimbursed at the rate of 100 % provided that the expenses relate directly to the illness. Patients may opt for the practitioner, hospital or clinic of their choice, even in a non-member country. Hospitalisation can, on request, be billed directly to the Joint Sickness Insurance Scheme, which will receive and pay the bills.

The costs of consultations, examinations, radiology, analyses, pharmaceutical products, surgical operations and other medical treatment (including emergency hospitalisation, blood transfusions, intensive care in isolation and treatment for immuno-deficiency) are reimbursed in full where they are directly related to the serious illness and where the costs do not fall within the scope of Annex I. XV.3 of the Rules on cover against the risk of occupational disease of officials of the European Communities, which specify that the Settlements Office, after consultation of the Medical Officer, may refuse to reimburse any expenses it considers excessive.

The costs incurred by a family member may be reimbursed at the rate of 85 %, after consultation of the Medical Officer and subject to a maximum limit of BEF 1 535 per day, where, in view of their age and the nature of their illness, patients require special family assistance and are accompanied to hospital by a member of their family on the practitioner's prescription (Annex I.III.3 to the Rules).

This amount, like all maximum limits specified in the Rules, is expressed in Belgian francs and is used as a reference for Belgium and countries outside the Community. Each year, equality coefficients based on the statistics available are used to adjust these maximum limits to the costs recorded in the various Member States but not in countries outside the Community.

The costs of transporting the patient and accompanying him or her from the country of residence to the country where the hospital is located and the costs of supplying services or products such as cosmetics, additional beverages, telephone or refrigerator rental, telephone bills, hairdressers' bills, subscriptions to newspapers or the purchase of periodicals etc. are not reimbursed.

In 1997, the Settlements Offices recorded a total of 5 cases where members who had been recognised as suffering from serious illnesses submitted claims for expenses incurred outside the Community (3 in Switzerland, 2 in the United States). In each case, the rules were applied in the manner described above. In one case, the Settlements Office, after consultation of the Medical Officer, considered certain expenses excessive and reduced the corresponding amounts in accordance with Annex I.XV.3.

It should be noted that diagnoses, being covered by medical confidentiality, are not communicated to the Settlements Offices, which cannot therefore reveal the nature of the illnesses in the abovementioned cases.