MEDICAL CARE

FURTHER EXPLANATION

-The Regulation facilitates the provision of cross-frontier medical services between Member States. It allows an insured person from one Member State to enjoy benefits in kind in the other Member States, whatever the national institution to which he is affiliated and whatever the place of his residence. The costs will be borne by the competent institution.
-The intention is in particular that the grant of sickness benefits should not be conditional on the residence in the competent Member State, so as not to deter Community workers from exercising their right to freedom of movement.
- The Regulation governs several situations: stay outside the competent State, return to or transfer of residence to another Member State during sickness or maternity, and the need to go to another Member State in order to receive appropriate treatment. Also special provisions are foreseen for people who reside outside the competent state.
- The first situation requires the need for benefits to be necessary.
- In the third situation the competent institution decides on the grant of authorisation for the insured person to go to another Member State for medical purposes and bears the cost of those services. The emphasis is placed on the person concerned obtaining the authorisation of the competent institution before he leaves. However, the Court has acknowledged that, where a request made by an insured person has been refused by the competent institution and it is subsequently established, either by the competent institution itself or by a court decision, that that refusal was unfounded, that person is entitled to be reimbursed directly by the competent institution by an amount equivalent to that which it would have borne if authorisation had been properly granted in the first place.
- Regulation must be interpreted as meaning that the insured person's right to the benefits in kind provided by the institution of the Member State of stay includes the treatment provided in that establishment, on condition that, under the legislation administered by that institution, it is obliged to provide a person insured with it with the benefits in kind corresponding to such treatment.
- The right thus conferred on the insured person means that the cost of the treatment given is initially borne by the institution of the Member State of stay, in accordance with the legislation it administers, and the competent institution is subsequently to reimburse the institution of the Member State of stay.
- In case someone resides outside the competent state, all benefits are provided under the legislation of the state of residence.
- The cost of the treatment provided must be borne by the institution of the Member State of stay in accordance with the legislation administered by that institution, under the same conditions as those applicable to insured persons covered by that legislation.
- Where the cost of the treatment provided has not been assumed by the institution of the Member State of stay, it is for the competent institution to reimburse to that person directly the cost of that treatment, so as to ensure a level of assumption of costs equivalent to that which that person would have enjoyed if the Regulation No 1408/71 had been applied.
- The competent institution is obliged to accept and recognise the findings and choices of treatment made by doctors authorised by the institution of the Member State of stay as if they had been made by doctors in the competent Member State.
- The competent institution is not entitled to require the person concerned to return to the competent Member State in order to undergo a medical examination there or to have him examined in the Member State of stay, nor to make the above findings and decisions subject to its approval.

RELEVANT ARTICLES OF REG. 1408/71

Article 19 Article 20 Article 21 Article 22 Article 22a
Article 24 Article 25 Article 26 Article 27 Article 28
Article 28a Article 29 Article 30 Article 31 Article 34a

QUESTIONS & ANSWERS
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