WRITTEN QUESTION E-0251/03

by Sergio Berlato (UEN), Cristiana Muscardini (UEN),Mauro Nobilia (UEN), Roberta Angelilli (UEN), Roberto Bigliardo (UEN),Antonio Mussa (UEN), Sebastiano Musumeci (UEN),Adriana Poli Bortone (UEN), Mariotto Segni (UEN)and Franz Turchi (UEN) to the Commission

(5 February 2003)

Subject: Health cover of Italian nationals resident in Belgium

Under current Belgian legislation, Italian nations resident in Belgium are obliged to have adequate health cover.

This requirement is a precondition for the recognition of certain fundamental rights, such as entry on the population register of a Belgian municipality and subsequent registration on the register of Italians resident abroad.

It appears that a significant number of Italian nationals are covered by the international E 128 agreement (established under Articles 22b and 22c of Regulation (EEC) No 1408/71(1)) which, among the various types of health cover available, stipulates that the medical expenses of Community citizens must be borne by their own country. In the case in point, Italy directly reimburses the INAMI, the Belgian federal organisation.

However, pending reimbursement by the health insurance organisations of which they are members (mutual societies), Italian nationals are asked to immediately pay in full for the healthcare they receive.

Unfortunately, Italians resident in Belgium are only reimbursed part of the costs they incur. They receive 75 % of these, calculated on the basis of an index called the INAMI code number, on a purely flat-rate basis.

Added to this is the fact that the rates charged in practice are actually always higher than this flat-rate amount, and that some hospitals employ doctors who are not registered with the INAMI and who therefore charge exorbitant amounts. It should also be noted that most of those doctors who do not charge the statutory INAMI rates do not inform the public of this by posting an appropriate notice in the waiting room, as is required under Belgian law.

Italian nationals covered under the E 128 agreement are consequently faced with having to pay large fees every time they require medical attention.

In the light of the above, will the Commission:

- ask the Belgian authorities to grant Italian nationals who are resident in Belgium and covered by the E 128 agreement complete compensation for the medical expenses they actually incur;

- ask the Belgian authorities to establish a suitable system for monitoring the activities of doctors not registered with the INAMI, thereby compelling them to advertise the medical fees they charge, in accordance with current Belgian law, in the interests of all Community citizens resident in Belgium?

(1) OJ L 149, 5.7.1971, p. 2.

Answer given by Mrs Diamantopoulou on behalf of the Commission

(12 March 2003)

The Commission informs the Honourable Members that there is no harmonisation of social security schemes at Community level. The Court of Justice has pointed out on several occasions that Community law does not detract from the powers of the Member States to organise their social security systems. In the absence of harmonisation at Community level, it is therefore for the legislation of each Member State to determine, first, the conditions concerning the right or duty to be insured with a social security scheme and, second, the conditions for entitlement to benefits. () Nevertheless, the Member States must comply with Community law when exercising that power(1).

Accordingly, Belgium has the power to establish its own sickness scheme and to set the conditions for granting sickness benefits. Exercising that power, Belgium has chosen a scheme commonly known as a reimbursement scheme, under which the patients go directly to see a health care provider of their choice to whom they pay the fees. The fees are then reimbursed on presentation of a statement of treatment, given by the health care provider, to the mutual benefit association(2).

Agreements are made between the insurance bodies and the professional organisations representing the medical services to set fees (standard fees) which, with regard to patients, should be respected by the doctors who have subscribed to these agreements. Under the agreement between doctors and sickness funds of 19 December 2002, doctors who have not given notification of their refusal to subscribe to the agreement, post a document in the waiting-room, and for the institutions in either the waiting room, the reception area or the registration office, which indicates whether they have subscribed to the agreement, as well as the consultation days and hours when the prices set by the agreement apply and those when they do not. It is also always possible to enquire at the mutual benefit association or at the National Sickness and Disability Insurance Institute (INAMI) whether a doctor has in fact subscribed to the agreement.

The patient is reimbursed for care by the mutual benefit association at a flat rate which, in principle, for ordinary medical aid is 75 % of the standard fees, whether or not the doctor consulted by the patient has subscribed to the fee-setting agreements.

The choice of this scheme is within the power of the Belgian authorities and cannot be challenged.

Whilst there is no harmonisation of social security systems at Community level, Community law has, however, instituted coordination of the national social security schemes in order to allow those people who are moving within the Union to benefit from the best possible social protection.

Regulation (EEC) No 1408/71(3) lays down provisions with a view to enabling people who are staying or residing in the territory of a Member State other than the State providing insurance to obtain medical care there. Forms have been drawn up to allow people who need medical care in the State where they are staying or residing to obtain such care on presentation of the appropriate form. For example, form E 128, quoted by the Honourable Members, allows people who are temporarily posted by their employer to the territory of another Member State to obtain the necessary medical care during their stay.

As a general rule, the principles of Regulation (EEC) No 1408/71 lay down that health care is provided according to the legislation of the Member State where the person receives treatment as if they were insured in that country, the costs of treatment then being chargeable to the institution in the State providing insurance for that person. In principle, this system ensures equal treatment of people residing or staying in the territory of a Member State.

Consequently, Italian nationals resident in Belgium who present form E 128 can claim the necessary care in Belgium, in accordance with Belgian legislation, as if they were insured there. Under the principle of equal treatment, they should therefore benefit from the same prices as Belgians who are insured, as the Court of Justice recently pointed out in the Ferlini judgment(4). Being subject to Belgian legislation, they are also obliged, in the same way as those insured in Belgium, to pay the health care providers the amount of the fees and then to apply for reimbursement from the mutual benefit association.

The Commission cannot, therefore, approach the Belgian authorities to obtain the right for Italian nationals to be fully reimbursed for the medical costs that they incur. Furthermore, since the sickness scheme organisation is exclusively a matter for Belgium, the Commission cannot intervene to obtain checks on doctors practising in Belgium. It could, however, intervene if it turned out that doctors or hospitals are charging people insured according to the legislation of other Member States higher prices than they are charging those insured in Belgium.

(1) Judgment of 28.4.1998, Case C-158/96, Kohll; judgment of 28.4.1998, Case C-120/95, Decker; judgment of 12.7.2001, Case C-157/99, Smits and Peerbooms.

(2) There are exceptions to this general principle, notably in the case of hospital treatment. In this case, the insurance body pays the health care provider the amount of the entitlement directly.

(3) Regulation (EEC) No 1408/71 of the Council of 14 June 1971 on the application of social security schemes to employed persons, to self-employed persons and to members of their families moving within the Community, last updated by Regulation (EEC) No 118/97, OJ L 28, 30.1.1997.

(4) Case C-411/98, judgment of 3.10.2000.