REPORT FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL on the use of travel medical insurance, under Article 15 of Regulation (EC) No 810/2009, by visa holders during their stay in the territory of the Member States
Date: 2021-03-02
Institutions: Directorate-General for Migration and Home Affairs, European Commission
Subjects: EU Member State, EU visa policy, admission of aliens, death, emergency medical treatment, free movement of persons, health care, health insurance, travel

EN 

  EN 

   EUROPEAN COMMISSION  Brussels, 2.3.2021  COM(2021) 92 final  REPORT FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL on the use of travel medical insurance, under Article 15 of Regulation (EC) No 810/2009, by visa holders during their stay in the territory of the Member States  
 
 
REPORT FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE 
COUNCIL 

on the use of travel medical insurance, under Article 15 of Regulation (EC) No 810/2009, by 
visa holders during their stay in the Member States 

I. 

Introduction 

Since  20041,  applicants  for  short  stay  visas  must  present  proof  of  “adequate  and  valid  travel 
medical  insurance”  to  cover  urgent  medical  treatment  or  repatriation  due  to  unforeseen  health 
problems  during  their  stay  in  EU  Member  States.  The  Council  decision  making  these  rules 
applicable  at  the  time  did  not  require  an  impact  assessment  and  no  other  form  of  in-depth 
analysis of the impact of the measure was carried out.  Without changes to the substance, these 
provisions were integrated into Article 15 of the Visa Code (Regulation (EC) No 810/2009).2  

While presenting adequate travel medical insurance (‘insurance’) is  a requirement for applying 
for a short stay visa, holding such an insurance is not a condition for entry3 to be checked at the 
EU’s external borders. Therefore, non-EU nationals who are not subject to the visa requirement 
and  future  ETIAS4  applicants  are  not  required  to  present  proof  of  holding  insurance  when 
travelling  to  the  EU.  This  leads  to  a  difference  of  treatment  between  visa-exempt  and  visa-
required non-EU nationals. 

In the 2014 proposal to recast the Visa Code, the Commission proposed to abandon the insurance 
requirement.  The  proposal  was  motivated  by  the  practical  challenges  linked  to  the  insurance 
requirement  (see  below),  the  fact  that  the  requirement  to  hold  insurance  is  not  checked  at  the 
external borders and, the fact that very limited evidence5 is available as to the actual enforcement 
of insurance policies. The Council rejected the proposal, which on the contrary found support in 
the European Parliament. In the end, the Commission withdrew its recast proposal in 2018. 

In its proposal on a targeted revision of the Visa Code in 2018, the Commission did not propose 
any changes to the provisions on insurance. The European Parliament and the Council agreed to 
task the Commission with drawing up a report to check the efficiency of this measure. Pursuant 

1   Council Decision of 22 December 2003 amending Part V, point 1.4,  of the Common Consular Instructions and 
Part I, point 4.1.2 of the Common Manual as regards inclusion of the requirement to be in possession of travel 
medical insurance as one of the supporting documents for the grant of a uniform entry visa (2004/17/EC),  OJ L 
5, 9.1.2004, p. 79. 

2   Regulation  (EC)  No  810/2009  of  the  European  Parliament  and  of  the  Council  of  13  July  2009  establishing  a 

Community Code on Visas (Visa Code),OJ L 243, 15.9.2009, p. 1.  

3   Article 6(1)) of Regulation(EU) 2016/399 of the European Parliament and of the Council of 9 March 2016 on a 
Union Code on the rules governing the movement of persons across borders (Schengen Borders Code), OJ L 77, 
23.3.2016, p. 1. 

4   European Travel Information and Authorisation System.  

Regulation (EU) 2018/1240 of the European Parliament and of the Council of 12 September 2018 establishing a 
European  Travel  Information  and  Authorisation  System  (ETIAS)  and  amending  Regulations  (EU)  No 
1077/2011, (EU) No 515/2014, (EU) 2016/399, (EU) 2016/1624 and (EU) 2017/2226, OJ L 236, 19.9.2018, p 1. 
 SWD (2014) 101 final. 

5 

1 

 
 
 
 
                                                           
to  Article  2(3)  of  Regulation  (EU)  2019/1155  amending  Regulation  (EC)  No  810/20096  the 
Commission  shall  produce  a  report  to  be  transmitted  to  the  European  Parliament  and  to  the 
Council on the basis of “relevant available data on the use of travel medical insurance by visa 
holders during their stay in the Member States, as well as costs incurred by national authorities 
or providers of medical services for visa holders” provided by the Member States.  

In  line  with  this  provision,  the  present  report  presents  the  challenges  (some  of  which  have 
previously been documented) with the insurance requirement, contains a general summary of EU 
Member  States’  responses,  including  on  the  possible  impact  of  the  COVID-19  pandemic  and 
suggests next steps. 

1.  Challenges in the visa procedure and lack of enforcement at the border 

While  acquiring  insurance  seems  unproblematic  for  applicants,  earlier  analyses,  frequent 
discussions  in  the  Visa  Committee  and  in  local  Schengen  cooperation  have  shown  that  the 
insurance requirement poses problems in several other aspects. 

  The legal basis 

Under  Article  15  of  the  Visa  Code,  applicants  must  present  proof  of  “adequate  and  valid” 
insurance that is  to  cover  “any expenses which might  arise in  connection with repatriation for 
medical reasons, urgent medical attention and/or emergency hospital treatment or death, during 
their  stay(s)  on  the  territory  of  the  Member  States.”  People  applying  for  a  multiple  entry  visa 
must present such proof for the first intended stay. Upon lodging the application, the individual 
concerned is made aware, by signing the application form, of the need to hold insurance for any 
future stays. 

The  insurance  is  to  cover  the  period  of  the  visa  holder’s  stay  and  in  EU  Member  States.  The 
minimum coverage is EUR 30 000 (level set in 2004) and claims must be recoverable in an EU 
Member State.  

 

 Timing to present insurance 

The  applicant  must  present  the  insurance  when  applying  for  a  visa.  Applicants  must  therefore 
present insurance covering the period of intended stay before knowing whether and for how long 
the  visa  will  be  issued.  Moreover,  some  consulates  incorrectly  insist  that  the  insurance  must 
cover the entire period of validity7 of the visa. Some consulates decide on the length of validity 
of  the  visa  based  on  the  validity  of  the  insurance  presented,  which  was  not  the  legislators’ 
intention. 

6   Regulation  (EU)  2019/1155  of  the  European  Parliament  and  of  the  Council  of  20  June  2019  amending 
Regulation (EC) No 810/2009 establishing a Community Code on Visas (Visa Code), OJ L 188, 12.7.2019, p. 25.  

7   Period of allowed stay: the number of days that the visa holder is allowed to stay, e.g. 30 days. 
  Period of validity of the visa: a period of 15 days is added to the period of allowed stay to allow the visa holder 
flexibility in using the visa (plans or flights may changes etc.), meaning that a person may hold a visa valid for 
45 days, allowing for a stay of 30 days. The travel medical insurance is to cover a period of 30 days.  

2 

 
 
                                                           
Some insurance companies allow for later cancellation of insurance policies. While this benefits 
people whose application has been refused, and who would otherwise have lost the money spent 
on the insurance, it is also a means to get around the requirement once a visa has been granted.  

Applicants must present proof of insurance cover for the first intended stay if they apply for or 
are eligible for a multiple entry  visa  with  a long  validity.  By  signing the application  form,  the 
applicants  are  made  aware  that  they  must  hold  an  insurance  for  subsequent  trips.  This  is  not 
checked upon entry and there is no evidence that the requirement is followed.  

  Consulates’ checks on medical insurance 

From  the  consulates’  perspective,  it  is  challenging  and  time  consuming  to  check  whether  the 
detailed  and  highly  technical  insurance  policies  actually  offer  the  necessary  guarantees  of 
coverage. The challenge is made greater because the very broad formulation of Article 15 of the 
Visa  Code  does  not  allow  for  quick  compliance  checks.  The  challenge  to  carry  out  thorough 
checks is also reflected by the problems reported by the health sector (see below).  

In some locations EU Member States have, following the exchange of information as provided 
by  Article  48(3)(d)  of  the  Visa  Code,  collectively  drawn  up  a  list  of  ‘recommended  insurance 
companies’  whose  products  have  been  checked  to  comply  with  the  requirements.  Apart  from 
making the assessment task easier for all, this is also an attempt to nudge applicants to  choose 
one  of  the  listed  insurances  and  therefore  limit  the  number  of  different  policies  presented.  In 
some  locations  having  such  lists  has  proven  a  powerful  tool  because  insurance  companies 
request to be included (even if no such formal application is envisaged) and are keen to remain 
on the list. A list of ‘recommended’ insurances can also reassure applicants that they are properly 
insured. In most locations, such collective assessment has been considered impossible because of 
the number of insurance policies available, including on the internet. That said, competition rules 
prevent  insurance  policies  being  rejected  on  grounds  that  they  are  not  on  such  lists  of 
‘recommended’ insurances if they fulfil the criteria set out in the Visa Code.  

  No verification at the external borders 

As mentioned, possession of insurance cover is  not  checked  at  external  borders.  It is  therefore 
left to the good faith of visa holders whether they hold a valid insurance that covers their period 
of stay when  crossing the external  border and  whether they  comply with the requirement each 
time they travel on a multiple entry visa (which may be valid up to five years).   

2.  Challenges reported by the health sector 

The  Commission  carried  out  preliminary  research  (2019-2020)  on  this  matter  by  contacting 
public  health  institutions  and  agencies  in  EU  Member  States.  Most  declared  not  being  able  to 
offer further insight into the use of insurance because such data are not collected centrally. That 
said, the following shortcomings were reported: 

  Frequent  absence  of  financial  cover,  either  because  no  insurance  was  taken  out  for  the 
duration of the stay, or because it expired before the end of the treatment (in particular if 

3 

 
 
 

 

the individuals’ stay had to be extended due to their health), or because it was knowingly 
terminated by the insured person before the end of his or her stay. 
Insufficient insurance coverage, in particular when the reimbursement ceiling for care is 
very low. There is  also  an issue of  coverage  for plannable care (e.g. nursing ward care 
following  treatment  in  the  emergency  room,  or  if  further  unrelated-treatment  is  needed 
following the emergency treatment). This is not (fully) covered by insurance policies. 
Insurance  companies  often  do  not  reimburse  costs  because  of  exclusion  clauses  or 
because a patient  has pre-existing medical  condition(s), i.e. medical  history that  greatly 
increases the probability that the risk covered may occur.  

  Disproportionate  requirements  for  reimbursement:  some  reimbursements  are  made  only 
under  conditions  that  are  not  compatible  with  medical  confidentiality  (e.g.  requests  for 
medical reports before reimbursement). 

  Patients  not  being  able  to  be  traced  after  they  have  been  discharged  and  difficulties  in 
contacting  the  insurance  company  abroad.  For  example,  the  patient  communicates  their 
insurance details to the hospital, but healthcare providers do not receive answers from the 
insurance companies. In the absence of a third party insurer covering the costs, hospitals 
are forced to invoice the costs directly to the patient, without guarantee of payment. 

  Most hospitals have a policy of advance price indication and then billing directly to the 

patient. This can obviously not be done in emergency cases.  

  Often  patients  need  to  stay  longer  than  the  validity  of  their  visa  or  to  be  transferred  to 

 

another hospital. In such cases, insurance companies refuse to pay. 
Issues also lie in the level the coverage, which is considered lacking to cover follow-up 
treatments  and  care  which  are  usually  never  covered.  Despite  this,  such  treatments  are 
often carried out.  

II.  Results of the 2020 survey on insurance and the costs incurred  

EU Member States were invited to provide “relevant data on the use of travel medical insurance 
by visa holders during their stay on the territory of the Member States, as well as costs incurred 
by national authorities or providers of medical services for visa holders” based on the following 
questions: 

  How are visa holders who require urgent medical treatment during their stay checked for 
having  adequate  and  valid  travel  medical  insurance?  What  happens  if  this  is  not  the 
case? 

  What data are collected about the healthcare provided to holders of short-stay visas and 

the insurance they hold? 

  Which organisation is responsible for the collection of such data? 
  What is the policy on unpaid healthcare bills? Are attempts made to recover such debts? 
What is the success rate of recovering unpaid medical bills from patients or the insurance 
companies? 

4 

 
 
 
  What  is  the  (estimated)  total  amount  of  unpaid  medical  bills  by  short  stay  visa  holders 
(2019)?  How  does  this  amount  compare  to  unpaid  medical  bills  by  other  categories  of 
non-EU  nationals  (visa-free  visitors;  people  holding  residence  permits  or  long-stay 
visas)?  

EU Member States were invited to gather input from the full range of public administrations and 
stakeholders in their country, including health authorities, insurance organisations and healthcare 
providers. 

1.  EU Member States’ replies  

All  EU-28  Member  States,  except  one,  and  Schengen  associated  states,  replied  although  the 
levels of information provided in responses varied considerably. 16 respondents had carried out 
investigations  through  various  government  bodies,  but  the  thoroughness  of  the  investigations 
vary. The remaining respondents limited their replies to declaring that ‘no data are available.’  

On  the  substance  of  the  replies,  the  common  feature  is  that  generally  there  is  no  formalised 
central  data  collection  on  healthcare  provided  to  non-EU  country  nationals  and  no  data  are 
collected on the legal basis of a given non-EU national patient’s stay (e.g. short stay visa holder, 
‘visa  free’  traveller)  when  he  or  she  receives  medical  treatment.  Some  replies  offer  a  detailed 
description  of  the  national  organisation  of  healthcare  and  payment  recovery  while  others  give 
very  broad  answers.  Some  EU  Member  States  shared  specific  figures  on  unpaid  medical  bills 
generated by non-EU nationals but calculation methods and periods covered do not allow for any 
meaningful comparison. 

  General guarantee of urgent medical treatment 

Generally, urgent medical treatment is provided by public hospitals in all EU Member States for 
all  people  irrespective  of  the  residence  or  visa  status  and  possession  of  medical  insurance. 
Additionally, a number of EU Member States have concluded bilateral agreements with certain 
‘visa  required’  non-EU  countries  concerning  medical  treatment  meaning  that  the  cost  of  any 
treatment is likely to be covered for visa holders who are nationals of those countries even if they 
do not hold insurance. 

  Checks on the possession of insurance by health institutions  

Holding an insurance is not a precondition for receiving medical treatment. However, most EU 
Member  States  note  that  depending  on  the  patient’s  condition  upon  admission,  medical 
institutions may require insurance before treatment but there is no uniform approach in place. In 
most cases, the patient is requested to show such proof after the treatment or to pay directly the 
hospital or, the later charges the insurer. 

Some  EU  Member  States’  medical  institutions  require  a  down  payment  by  the  patient  (e.g. 
amounts of 300 EUR or less) making insurance  recovery irrelevant.  Others require  all non-EU 
residents or, if relevant, an inviting person/sponsor, to pay the treatment directly. 

5 

 
 
 
  Lack of data to determine if visa holders use their insurance 

When collecting patients’ personal data, information on their nationality may also be collected. 
The conditions of stay (i.e. whether the individual holds a visa or a residence permit) of people 
who have been treated are not collected centrally, but may be kept at hospital or regional level. 
Some EU Member States have carried out ad hoc surveys on non-EU nationals having received 
medical treatment, but without distinguishing between conditions of stay or coverage of bilateral 
agreements on medical treatment.  

Three  EU  Member  States  have  indicated  that  random  checks  are  conducted  at  the  external 
borders to check if visa holders hold a valid insurance. One of the three indicates that absence of 
an insurance policy may lead to revoking the visa on the ground that one of the conditions for 
granting the visa is no longer met. 

  Recovery of unpaid medical bills 

No EU Member State appears to apply cross-cutting rules or guidelines for recovery of unpaid 
hospital  bills.  This  is  also  due  to  the  decentralised  set  up  of  healthcare  in  most  EU  Member 
States that leaves it to the individual institution to set its own practice. 

All EU Member States confirm that recovery from individuals or insurance companies abroad is 
extremely challenging (time consuming and costly).  

In some EU Member States, national ‘re-insurers’ exist in the form of public agencies under the 
ministry of health that cover hospitals’ costs for unpaid bills but has no means to seek recovery 
from the patient or the insurer. 

Several  EU  Member  States  indicate  estimates  of  unpaid  medical  bills  for  treating  foreign 
nationals (without distinction of nationality) ranging from 10% to 60%, but only one shared data 
on  unpaid  medical  bills  specifically  by  short  stay  visa  holders  from  one  region  of  the  country 
(65%). That  EU Member State also  indicates that the rate for unpaid  medical  bills  for non-EU 
nationals  that  may  travel  visa  free  (and  free  of  insurance)  to  the  EU  is  62%.  Against  this 
background, it is difficult to argue that the requirement makes a real difference. 

2.  Current situation: no clear picture  

There are considerable differences in the experiences between EU Member States, due mainly to 
the  differences  in  healthcare  systems.  Urgent  medical  treatment  is  offered  universally  and 
covering  the  cost  is  a  secondary  matter.  In  some  EU  Member  States,  bilateral  healthcare 
agreements with non-EU countries cover medical treatment regardless of whether the individual 
concerned holds insurance or not.  Situations also differ depending on whether healthcare takes 
place under a private commercial ‘contract,’ is provided directly by state institutions or, a mix of 
the  two  where  the  state  is  the  ‘re-insurer.’  EU  Member  States’  estimates  of  the  amounts  that 
unpaid medical bills represent vary widely. Some EU Member States judge that the problem is 
insignificant, stating that ‘visa holders pay their medical expenses,’ without providing evidence. 
Others consider this to be a matter of major concern noting the coverage threshold of EUR 30000 
is insufficient. 

6 

 
 
As  possession  of  an  insurance  is  not  an  entry  condition  and  therefore  not  checked  upon  entry, 
there is no evidence that visa holders hold the appropriate insurance each time they travel. 

Furthermore,  precise  data  collection  on  unpaid  bills  by  short  stay  visas  holders  is  difficult  and 
appears  non-existing.  So,  the  reasons  for  unpaid  bills  (incurred  by  non-EU  nationals)  remain 
unknown and clarity is needed on a number of aspects, such as:  

  What is the share of short stay visa holders in need of urgent medical treatment during 

 

their stay that do not hold any insurance or hold insufficient insurance?  
Can insufficient  insurance  cover be  explained by  the fact  that the current  legal  basis 
does not clearly spell out the requirements for an insurance to be considered adequate? 
Is the level of coverage (EUR 30 000) too low to cover all costs?  

 
  What  are  the  reasons  for  insurance  companies’  refusal  to  cover  incurred  medical 

costs?  

  Why do medical institutions not seek recovery? Is it because of the low success rate or 

because in the end the central authorities cover the debts? 

An  additional  but  significant  issue  is  that  there  is  no  evidence  that  visa  required  non-EU 
nationals  present  different  problems  for  healthcare  compared  to  non-EU  nationals  who  may 
travel visa free to the EU8 (see above). It is therefore highly questionable whether the different 
requirements between these categories of travellers are justified.   

In  their  replies,  some  EU  Member  States  argue  that  the  requirement  should  also  be  seen  as  a 
means  of  protecting  travellers  in  case  they  would  need  urgent  medical  treatment  during  their 
stay. However, this concern should apply to all non-EU nationals travelling to the EU. 

3.  Impact of the COVID-19 pandemic 

The  COVID-19  pandemic  and  the  ensuing  worldwide  travel  restrictions  put  a  sudden,  almost 
complete stop to visa operations from end March 2020 and a high number of visa holders present 
in EU Member States who were unable to leave by the expiry of their visa. The pandemic further 
highlighted  the  pressing  need  to  evaluate  the  effectiveness  of  insurance  and  the  following 
questions were put to Member States: 

  What is the impact of the current COVID-19 pandemic? Have you noticed any changes in 
unpaid healthcare bills during this period? If such data are not available yet, you should 
indicate when they will be.  

  What  are the provisions on health insurance and medical  care that apply to  holders of 
short-stay  visas  who  have  to  remain  in  the  Schengen  area  for  longer  than  90  days 
because of the COVID-19 pandemic? 

8   In 2019, around 15 million short stay visas were issued and of these more than 50% were multiple entry visas. By 
comparison  the  report  on  the  ‘Technical  Study  on  Smart  Borders’  concluded  that  the  indications  for  expected 
traffic at external borders in 2020 for “visa free” non-EU nationals would be 104 million.  

7 

 
 
                                                           
 
EU  Member  States’  replies  to  these  questions  were  very  similar:  it  is  too  early  to  determine 
whether  the  pandemic  has  had  an  impact,  but  the  low  numbers  of  non-EU  national  travellers 
(‘visa free’ or ‘visa required’) suggest that there will be no impact. Most EU Member States did 
not  require  involuntary  ‘overstayers’  to  take  out  insurance  for  their  extended  stay  and  any 
emergency  treatment  was  given  during  that  period.  People  in  need  of  other  types  of  medical 
treatment during their extended stay would have to cover the costs themselves.  

By November 2020, EU Member States restarted to process the low-levels of visa applications 
around the world, and an insurance-related aspect directly linked to the COVID-19 pandemic has 
emerged. Spot checks carried out in April 2020 show that several major insurance companies are 
now offering insurance policies containing specific clauses that exclude medical costs linked to 
an  epidemic  or  pandemic  outbreak  from  coverage,  or  cover  them  only  in  part.  Similar  trends 
have also been reported by EU Member States consulates.  

III.  Next steps 

The  picture  is  not  conclusive  as  to  the  efficiency  of  the  current  insurance  requirement.  This 
report shows that relevant and solid data are missing that would allow the Commission to fully 
assess the efficiency of the current rules. There is, however, ample evidence of the challenges for 
different actors in the implementation of the measures and the following conclusions can already 
be drawn: 

1)  There  is  no  evidence  to  suggest  that  the  current  insurance  requirement  provides  a 
significant  relief  for  healthcare  systems  by  ensuring  payment  of  treatment  because  the 
problem of unpaid bills remains. Additionally recovery of unpaid hospital bills appears to 
be  a  considerable  problem,  even  in  cases  where  the  patient  holds  an  insurance  at  the 
moment of the treatment. 

2)  The  following  weaknesses  in    the  way  the  current  requirement  is  designed  can  be 

identified: 

  The timing of the presentation of proof (upon lodging the visa application). 

  The broad, unclear and  possibly outdated rules  on insurance  coverage, therefore 
making it difficult for consular staff to check that the insurance is compliant.  

  Actual  possession  of  insurance  is  not  checked  when  the  visa  holder  crosses  the 

EU border. 

3)  The information provided by EU Member States indicates that the absence of equivalent 
requirements for visa-free travellers could be part of the problem of unpaid hospital bills 
as there is no evidence that visa required non-EU nationals present different problems for 
healthcare compared to non-EU nationals who may travel visa free to the EU. 

Several options for follow-up action could be envisaged: 

  Accept  the  current  situation  without  any  real  evidence  of  benefits  for  health  systems 
despite  the  known  problems  for  visa  applicants,  the  challenge  for  consulates,  the 

8 

 
 
embedded  structural  problems  and  the  lack  of  data  available  that  would  allow  an 
assessment of whether the insurance requirement is actually applied as intended. 

  Acknowledge  that  the  legal  basis  is  outdated  (drawn  up  17  years  ago)  and  must  be 
improved to ensure that it serves the intended purpose, namely that visa holders hold an 
adequate  insurance  during  their  stay,  for  example,  by  defining  precise  policy 
requirements that insurers must refer to explicitly in their policy (‘Guaranteed EU travel 
medical  insurance  minimum  standard’).  Provisions  could  include  standard  payment 
procedures  to  ensure  recovery  of  costs;  the  possibility  of  extended  coverage  in  case  of 
stays  beyond  the  expiry  of  the  visa  due  to  prolonged  treatment;  and  the  possibility  of 
continuous coverage for holders of multiple entry visas (‘pay as  you go’). A ‘guarantee 
label’ could also, particularly when the visa procedure becomes fully digitalised, enable 
consulates’  ability  to  check  that  the  insurance  policies  presented  by  visa  applicants 
comply with the legal requirement.  

  Recognise the fact that there should be no different treatment between visa-required and 
visa-free  non-EU  nationals  for  insurance  coverage  during  their  stay  in  the  EU  and 
consider extending the insurance requirement to  visa-free travellers, while ensuring that 
compliance is checked at the appropriate moment (i.e. when travel takes place). 

To seek clarity on the efficiency of the insurance requirement and of the possible need for a 
revision  of  the  legal  basis,  the  Commission  intends,  building  upon  this  report,  to  launch  a 
study to collect additional data. 

9