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NHS refusing to pay for treatment in France


CeeJay

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In 2009 whilst still in the UK health care system and visiting my house in France I fell ill and went to the local hospital, the only one in fact by a mile! I duly received treatment and showed them my EHIC which they took a copy of. Some 18months later I had a letter from CPAM saying that as I was not in the French system I had to pay just over 2000Euros for this treatment. At this point I had in fact received my carte vitale.

The invoice was paid and then I duly claimed the money back from the NHS. I have now received a letter from the Overseas Health Care team saying that the claim has been refused because I went to a private hospital for the treatment!

I am at a loss to understand this reasoning, surely all normal,usual hospitals in towns up and down France are of the same ilk. I live near Montpellier and am now aware that there is a hospital which is directly funded by CPAM in Montpellier, but I didn't know at the time and as I was a visitor how was I supposed to know?

If I require emergency treatment, which I did, am I supposed to look in the yellow pages and ring around trying to find a public(?) hospital. Further, why does CPAM recognise these hospitals and gives the usual allowances for treatment received there, if they are not part of the overall system?

I would be interested to know if anyone else has had this problem and how to resolve it.

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Was the bill from the CPAM for the full amount or perhaps just the 30% (plus other bits) that was not prise en charge? If that was the case then the UK would not be liable for it, if it was for the full amount then its too late now but having seen and validated your EHIC they should have only  billed you the 30%.

Did you perhaps have a private room? The supplement for this I doubt the UK would be liable for and perhaps it was that is confusing them thinking that it was a private hospital, was the bill from the CPAM or the hospital? If the former there really should not be any dispute.

The 18 months makes me think that they did not process this via the correct channels, normally they validate the EHIC and get paid straight away from the CPAM, they would invoice you quickly for the 30% at your charge, I had one operation where it all went wrong and like you I ended up paying, this was also after 18 months, I think it takes their clerks that long to process anything out of the ordinary. I disputed it, it was clear cut, a repeat of the operation they carried out the week before but botched which went through as normal, however they refused to re-visit the dossier, my dossier contentiux became lost, the usual story and I ended up paying.

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I was thinking along the same lines as Chancer, you need to ask for the full bill and see. When I was in hosptial my bill came to 7000€ approx and my mutual paid a huge lump of this amount. If I hadn't had a mutualist then we would have had to pay the difference.

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I've just done a bit of googling and I'm afraid that the guidelines given for the EHIC specify that it only covers treatment in state hospitals and they exclude private health care. I agree that this is a minefield, especially in an emergency, but the rules are clear and it looks like they are enforcing them in your case. [:(]

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The problem is that, as CeeJay has mentioned, private 'cliniques'  which are funded privately and exist to make a profit, are re-imbursed exactly in the same way as the Public CHU for people in the French system, and the money comes from the same pot. Many of these establishments also run an emergency department in the same way as the local Hospital

This blurs the distinction between private and public, so that there is nothing like the difference that there is in the UK between a NHS hospital and , say, a BUPA clinic.

I agree that for a British visitor this would be very confusing, and that with the best will in the world it would be possible to go to a 'clinique' rather than a hospital. In addition a French neighbour etc would not be able to advise, as they would have no idea that this could be an issue.

I have posted before on the way in which these 'cliniques' abuse the fact that they are reimbursed from the public purse, often ordering multiple tests which are scarcely justified, but which are lucrative. This is one reason why they often have a good reputation: people treated in their emergency department are given a very thorough (and very expensive)  check-up which is totally paid for, except for people who are not fully in the system.

I feel that this is one of those thorny issues which will have to be grasped at some point: the Right want to save money but have an interest in the firms that run these 'cliniques', while the Left oppose anything that smacks of cuts in health care.

In the meantime this does not help CeeJay, who has raised a very important issue for those who depend on EHIC cards, such as people with holiday homes not permanently resident in France.

In Montpellier the 'standard' Urgences is La Peyronnie.

Perhaps everyone in this situation should familiarise themselves with their local equivalent?

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I have always , perhaps wrongly, assumed that in an emergency emergency the pompiers would automatically take the patient to state controlled hospital.

Of course in most cases it wouldn't matter, from a financial aspect, as the travel insurer isn't bothered by the distinction.

At this late stage there may well be problems in getting any insurer involved owing to the delay in notifying the claim.

PS it's interesting to note that this mix of prrivate and public is the exact same formula which is being introduced into the NHS
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[quote user="NormanH"]In the meantime this does not help CeeJay, who has raised a very important issue for those who depend on EHIC cards, such as people with holiday homes not permanently resident in France.[/quote]

It also highlights the fact that an EHIC is not a substitute for proper travel insurance.

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[quote user="BJSLIV"]I have always , perhaps wrongly, assumed that in an emergency emergency the pompiers would automatically take the patient to state controlled hospital.[/quote]

I would very much hope that in a real life or death emergency they would take the patient to the nearest facility able to treat them without any thoughts of costs even entering their minds !

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I was assuming that every area would have a hospital conventionee providing the normal emergency cover.

It would then be these hospitals that would tend to be chosen by the pompiers rather than an alternative the non conventionee.

If a claim has been turned donw by the NHS the hospital must be outside the state systerm, rather than just being privately owned. Many French hospitals are private but still form part of the state system and would therefore qualify for EHIC reimbursement.

After all in the UK you don't get taken to the nearest private hospital.

I don't

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[quote user="BJSLIV"]I was assuming that every area would have a hospital conventionee providing the normal emergency cover.

It would then be these hospitals that would tend to be chosen by the pompiers rather than an alternative the non conventionee.

If a claim has been turned donw by the NHS the hospital must be outside the state systerm, rather than just being privately owned. Many French hospitals are private but still form part of the state system and would therefore qualify for EHIC reimbursement.

After all in the UK you don't get taken to the nearest private hospital.

I don't[/quote]

Isn't this the point? CeeJay seems to have found out that they don't qualify.

I don't personally know of any hospitals outside the system, at least in my part of France.

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The practice of taking patients to private clinics is quite common in Spain I believe but here in France I don't know.

There may be something to the suggestion that the €2000 bill is the balance of the 70% that CPAM might have been expected to pay though so getting hold of a copy of the entire bill would be useful.

At the end of the day your EHIC entitled you to exactly the same level of reimbursement as a French national so if CPAM would have covered 70% of the conventional tariff at that particular clinic for them then UK should match it for you.

The NHS may have legitimately refused you but stated the wrong reason. Not being nosy but if you said what the emergency treatment was it may be possible to put some sort of ball park price on it to judge whether or not €2000 would have covered it.

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[quote user="BJSLIV"] Many French hospitals are private but still form part of the state system and would therefore qualify for EHIC reimbursement. [/quote]

Precisely, I am having my coloscopy done in a private clinic, it is one of many on the campus of L'hôpital Amiens Nord, I was referred there by my generaliste, the surgeon has a permanance at my surgery and he and the anaesthetist are conventionnée, I was assured that it would be 100% prise en charge by the Secu and that would also be the case for a French citizen with a mutuelle.

On the basis that an EHIC gives the holder the same rights as a native of the country where the operation is carried out, the NHS should have paid for it unless we are indeed talking about a bill for the remaining 30% plus forfait journalier, out patient appointments etc.

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KathyF said that her Googling showed that private clinics are not reimbursed by the EHIC.

I still maintain that I don't know any private clinics in the English sense, but if CeeJay has been refused it seems that the sort of 'clinique' that we have here, privately funded, but re-imbursed by the Sécu, may have been considered as a 'private'  one by the NHS.

Some quotations: The card gives access to reduced-cost or free medical treatment from state healthcare providers.

It will not cover any private medical healthcare.

you should be able to get the same treatment as a resident of the country you're visiting.

http://www.nhs.uk/NHSEngland/Healthcareabroad/EHIC/Pages/Introduction.aspx

This is where the possibility of confusion arises, if someone from the NHS  in the UK interprets a 'clinique' as being private in the UK sense.

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I used to live near a city and there was a state hospital and many cliniques, but only one proper Urgences. Your ticker's not beating, a stroke and there was only one place to go, was the state hospital.

I cannot say that we haven't been to the A&E's a the cliniques,we have, they would deal with a broken arm or sprain, simpler bobo's really. And I'm wondering if they were open 24 hours a day too, of that I'm not sure. I just know where I would have gone.

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I think that has changed in the last few years idun.

10 years ago that was certainly the case, but now in my town of 80,000 we have the hospital and 2 other cliniques offering 'Urgences'.

One of the cliniques I wouldn't touch, but I have been to the other a couple of times. A good example of what I was talking about in an earlier post was the time when I tripped over and hurt my ankle.

I was taken by ambulance to the Hospital, who took an Xray, said there was nothing wrong, and told me to get a taxi home and take some paracetamol.

After 2 weeks of agony I took a taxi to the clinique, pretending that I had just fallen over, and they also took an Xray and found that I had a broken small bone, the 'malleol'.

So far it sounds as if the clinique was far superior, and insofar as they found the problem it was.

But at the same time the Cardiologist was called to give me a consultation ( billed to the Sécu) and I was given a scan (likewise) to see 'why I had fallen over'

A whole series of  follow-up appointments were also made, with the consultants who make up the team who own the clinique obviously.

So there you have the two sides of the picture.

In terms of CeeJay's bill, I wasn't clear if there was a hospital stay involved after the visit to the emergency.

If there was there could easily be a number of charges which built up which would not be covered by a EHIC, such as the cost of a single room, or the 18€ a day charge.

Even with 100% French cover and a Mutuelle my bill for my long stay last year came to over 3000€ of these apparent extras

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[quote user="idun"]

I used to live near a city and there was a state hospital and many cliniques, but only one proper Urgences. Your ticker's not beating, a stroke and there was only one place to go, was the state hospital.

I cannot say that we haven't been to the A&E's a the cliniques,we have, they would deal with a broken arm or sprain, simpler bobo's really. And I'm wondering if they were open 24 hours a day too, of that I'm not sure. I just know where I would have gone.

[/quote]

 

Well the clinic here shuts A&E at 20.00 or 21.00hrs - big plaque on wall giving "opening" hours outside.

However I won't knock them because I have just got eye appointments 7 months earlier than all the private Opthals in town, two of which have closed their books currently and our usual one is giving appts approx 14months in the future unless you have diabetes needs.

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NormanH

Yes the bill did include private room etc etc etc, but the main thrust is that these Polycliniques are part and parcel of the French system and the State reimburse their citizens accordingly. At the Polyclinique I went to there is a 24 hr Accident & Emergency clinic and the Pompiers take their accident victims etc to this Clinic, they do not travel 40ks down to Montpellier!!

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A private room should make no difference. Within the NHS there is a push to greatly increase the number of single rooms - this is part of an annual return that trusts have to make:

04Single bedrooms for patients with en-suite facilitiesNo.The total number of available beds that are single bedrooms provided for patient use which have en-suite facilities. An en-suite facility can include a WC and wash handbasin only or a WC with shower/bath and wash handbasin. The total of S02.04 and S02.05 should equal the total number of single bedrooms for patients use (Not applicable to Ambulance Trusts).
05Single bedrooms for patients without en-suite facilitiesNo.The total number of available beds that are single bedrooms provided for patient use which do not have en-suite facilities. The total of S02.04 and S02.05 should equal the total number of single bedrooms for patients use (Not applicable to Ambulance Trusts).

Paul

 

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A private room, unless given unasked for a medical reason is an 'extra' which has to be paid either by the individual or the Mutuelle. It is not reimbursed by the Securité Sociale, so if the EHIC gives the holder the same rights as a French person the room would have to be paid for (at around 40/50 € a day) . The daily charge of 18€ also has to be paid for.

So it could easily come to 60€ a day for a French person in the French system.  The same would apply to a EHIC holder.

I don't see the relevance of what happens in the NHS about private rooms. This is about France, and what happens here and what has to be paid for here.

Don't forget that the cost of the stay may also not be reimbursed at 100%.

Attention : quelle que soit votre situation, cette

prise en charge à 100 % par l'Assurance Maladie ne s'applique ni au

forfait hospitalier,
lorsqu'il est dû, ni aux frais de confort

personnel.

Frais d’hospitalisation et remboursement

Si vous êtes

hospitalisé dans un établissement public ou une clinique privée

conventionnée, l’Assurance Maladie rembourse vos frais d’hospitalisation

à 80 %. Votre mutuelle peut prendre en charge les 20 % restant, ainsi

que certains suppléments ou dépassements d’honoraires. Le forfait

hospitalier reste alors à votre charge, sauf si vous remplissez les

conditions d’exonération.

Si vous choisissez une clinique privée non conventionnée, les frais

restant à votre charge seront plus importants.

Les frais pris en charge

Dans un hôpital public ou une clinique privée conventionnée, les frais liés à l'hospitalisation sont pris en charge à 80 %

par l'Assurance Maladie (sauf cas particuliers). Vous serez remboursé

après envoi à votre caisse du bon de sortie remis par l'établissement de

soins lorsque vous le quittez.

L'Assurance Maladie prend en charge également une partie des soins réalisés avant ou après une hospitalisation.

Vous

serez, par exemple, remboursé à 70 % lors d'une consultation chez un

anesthésiste, avant une opération, et à 60 % si vous avez besoin de

séances de rééducation après une intervention chirurgicale.

Les frais qui restent à votre charge

À votre sortie d'hôpital, vous aurez à régler :

  • le montant du ticket modérateur,

    c'est-à-dire la partie des dépenses de santé qui reste à votre charge

    après le remboursement de l'Assurance Maladie (20 % des frais

    d'hospitalisation), ainsi que le forfait journalier ;
  • les éventuels suppléments pour votre confort personnel , comme une chambre individuelle, le téléphone, la télévision, etc. ;
  • les dépassements d'honoraires médicaux.

Toutefois,

si vous avez une mutuelle ou une assurance santé complémentaire, ces

frais peuvent être remboursés en partie ou en totalité. Renseignez-vous

auprès de l'organisme pour savoir si votre contrat le prévoit.

I am in no way attacking you CeeJay.

I am trying to help you see where this sum of 2000€ might originate.

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OK wires crossed [:)]

In brief, I think some of the charge may be justified by the extras which a French person, or the top-up, would have had to pay as well, but that this may also be compounded by some one in the NHS admin in the UK who dealt with your file and didn't understand the difference between a 'clinique' in France, which, while privately funded is reimbursed for French nationals, and a private clinic in the UK.

If that isn't the case, as I said earlier it raises questions about where people on a EHIC should try to go if at all possible.

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I just think that if you haven't got a proper copy, you need to see the full bill and see what has been charged for properly. Do you realise that the french may have already claimed what they could via the EHIC? And the rest could well be down to you. French hospitals can be expensive one way or another.

I am curious as to why you hadn't got travel insurance, I would never believe an EHIC to be enough, or a CEAM to be enough either whilst travelling, I don't want the bills, so I buy insurance.

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[quote user="idun"]

I am curious as to why you hadn't got travel insurance, I would never believe an EHIC to be enough, or a CEAM to be enough either whilst travelling, I don't want the bills, so I buy insurance.

[/quote]

EHIC is free - you have to pay for insurance or in this case, pay for not having it.

John

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Norman the relevance with the NHS is that they have private rooms and the aim is for 50% of beds to be in private rooms. Therefore, someone receiving treatment within the NHS in a private room is something that does occur - and with the increase of private rooms becoming more and more common. Therefore, the French system using private rooms is similar to what is happening within the NHS.
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