The cost of free treatment -
Spanish hospitals 'refuse' EHICs, allege travellers
It has been alleged that some public hospitals in Spain have refused to accept travellers’ European Health Insurance Cards (EHICs) when they attempt to access treatment. James Paul Wallis investigates what customers say they are experiencing and asks what help is available for travellers who have problems trying to access healthcare under the EHIC
My personal experience of using the EHIC to access healthcare while abroad was entirely positive. It was my own personal version of the Ben Stiller movie Meet the Parents. While trying to charm my future in-laws in Poland (who were far, far friendlier than Robert De Niro’s character in the film), I was hit by a nasty stomach bug. I wound up in the local public hospital, where they gave me an IV for rehydration and sent me on my way. The wait was short, the red tape minimal (a flash of the EHIC and a simple form to confirm my personal details), and the staff professional. No request for credit card details was made that might lead me to think that I might be charged for the treatment myself, and no travel insurance claim was required. It was just what you want when you’re already feeling sickly and out of your depth, and how I’m sure any EHIC holder would expect to be treated. However, allegations are rife that travellers to Spain, in particular, may not have such an easy ride.
EHIC theory – how it should work
To recap how the EHIC system is meant to work, these are the rules of the game, as stated on the European Commission (EC) website: “When you show your EHIC, you will receive treatment under the same conditions and at the same cost (free in some countries) as people insured in that country.” Explaining what travellers are entitled to in Spain, the EC website says: “Public hospitals offer treatment free of charge. Make sure you show your valid European Health Insurance Card on admission, otherwise you will be charged as a private patient. Costs incurred for private treatment are not refundable.”
There are various provisos as to which treatments are covered under the EHIC in Spain, but it’s clear that the expectation is that emergency treatment in public hospitals should be available to cardholders completely free of charge. And they don’t even need to have their cards with them at the time – the EC explains that ‘your health insurance provider will issue you with a provisional replacement certificate and, in more urgent cases, can send it to you by fax or email in the country where you are staying’.
To briefly cover the money trail, in Spain, the hospital should report the treatment to the health authority in the autonomous region in which it is based (e.g. Valencia, Galicia, Andalusia), which then tells the national Ministry of Health, which informs the authority that issued the EHIC in the patient’s native country, which finally issues a payment that should follow the reverse route back to the autonomous region. This takes place ‘behind the scenes’, with the patient receiving no bills or further contact.
Sound simple? Well, here’s a complication: alongside the public and private hospitals described in the EHIC info on the EC website (‘hospitales publicos’ and ‘hospitales privados’), the Spanish health system boasts numerous ‘hospitales concertados’, which are privately owned, but provide public services under contract to regional state authorities. Although a spokesperson for the EC told us that hospitales concertados should accept the EHIC, a response from the MSSSI (the Spanish Ministry of Health) suggested that the situation may be less clear cut – more on this below.
The allegations – EHIC ‘refused’
The word coming from the travel insurance industry is that tourists from several European countries are experiencing difficulties with the system, with allegations that hospitals are more concerned with credit card and insurance details than an EHIC. The following examples are taken from the stories that have been reported to ITIJ. For legal reasons, the names of people and locations involved in the individual cases have been omitted as they are subject to ongoing litigation.
Case 1: In June 2012, a Dutch national was admitted to a hospital concertado in Spain with serious health problems. He presented his EHIC in the emergency department, but despite this, the hospital asked for a copy of his credit card – which he refused to give. Netherlands-based ANWB, acting as the assistance company for his health insurer, contacted the staff dealing with the case on behalf of the hospital, who denied that the hospital had requested a copy of the credit card.
The following day, the patient informed ANWB that he had been repeatedly asked for payment for his hospitalisation, and ANWB suggested that he could again present his EHIC to the hospital administration staff. Caroline Hondius, ANWB’s director, Spain and Portugal, told us that the patient was ‘not amused that he had to worry about these things’, given that he had valid insurance.
On the third day, ANWB again asked the patient to present his EHIC to the admissions staff, but saying he had already showed his card ‘several times’, he did not want to go again. After a long conversation with his wife, she agreed to go on his behalf, but said it would be the last time.
Soon afterwards, the patient made a formal complaint to ANWB over the handling of the case by both ANWB and the hospital.
Case 2: An AXA Insurance customer who had fallen and injured his leg sought treatment at a public hospital in Spain, presenting his EHIC on admission. However, he was told the EHIC would not be accepted, and he needed to provide details of either his credit card or insurance. Ian Jones, lifestyle claims technical manager, AXA Insurance, explained: “Initially, [he] refused [to provide this information] as he was well aware that his EHIC should be accepted. [He] reports that when it became apparent that the facility was not prepared to treat him, he provided his insurance details. He didn’t want to as it meant that he had a high excess to pay and feels that he was discriminated against. [He] reported that the admissions team at the facility were aggressive and that he was extremely distressed during his admission at [the hospital].”
Case 3: In another AXA case concerning a traveller in Spain, a boy suffered a fall that resulted in damaged teeth and cuts to the inside of his mouth. His father took him to a hospital concertado and presented his EHIC. The facility refused to treat the boy without a credit card or insurance details, but the father challenged this as he knew what his rights were. However, the hospital still refused to treat the boy and, because he was in pain and becoming very distressed, the father took him to another facility, which did accept the EHIC.
The above stories are typical of the many allegations we’ve seen. There are also suggestions that admissions staff have advised patients that the EHIC cannot be accepted if they have private travel or health insurance in place.
So, if the patient does have personal travel cover, then in theory they should be fine – provide proof of cover, call the assistance company to notify them and let the insurer and hospital negotiate the bill. If, however, the patient has neglected to purchase travel insurance for their trip, then the cost of treatment for even something as simple as a broken arm could run into thousands of euros should there be a complication. And what if it’s not a broken arm? Falls from hotel balconies are disturbingly common in popular tourist resorts in Spain and if the hospital treating that patient does not accept an EHIC in lieu of payment or insurance, then that patient and their family could find themselves very quickly in dire financial straits.
The two crucial questions are what really happened to these patients, and whether the hospitals concerned (which are a mix of public hospitals and hospitals concertados) do fall into the EC’s category of ‘public’ hospitals that should accept the EHIC.
Fact or fiction
It would be difficult to prove beyond doubt exactly what took place in any of these cases, especially if the alleged ‘refusal’ of the EHIC was said to have been made verbally by admissions staff with no paperwork as proof. After all, would any provider that should accept the EHIC have an official policy of refusing EHICs or leave a paper trail showing this?
And there can be benefits to the traveller if they elect to use their private insurance in lieu of the EHIC, explained Maria Reales, communications director of Gestitursa, a company that, among other things, helps Spanish public hospitals (including hospitales concertados) to obtain payment for medical treatment given to foreign patients. Those whose cases are being handled by Gestitursa, for example, may be treated sooner than patients using the EHIC in the same hospital, and also are attended by a dedicated Gestitursa patient assistant team located in the hospital, which offers support and guidance to patients that includes translation services.
Perhaps, then, it is the patients who are electing to rely on their travel insurance, and not the hospitals that are choosing to decline the EHIC. However, we spoke to Jose Afonso, operations manager of ONE Assist, who affirms that, in his company’s experience, if the EHIC is presented, the hospitals usually accept it as evidence of entitlement to treatment, but decline it as a valid method for payment, so he questions whether travellers are really being given a free, informed choice with no pressure or enticement to sign themselves in as private patients.
To see if we could replicate the alleged refusals, we called a hospital concertado in Spain (see transcript in the box out on p.10), posing as a tourist whose wife was unwell, and asked whether she could be treated under the EHIC. We were told that payment could be taken through the EHIC for out-patients only – in-patients would need to settle the bill themselves or have the hospital charge their private (travel/health) insurer.
Wider issue?
We wanted to know if anyone outside the travel insurance industry recognises that there is an issue here. Maria Reales told us: “All Spanish public hospitals (and hospitales concertados) accept the use of the EHIC by European citizens in order to receive care for a medical emergency.” She added that where the patient holds private insurance that covers medical treatment, ‘only the patient has the power to decide what form of cover is used (the EHIC or private insurance) and gives their consent so that the hospital can charge the treatment and additional services to the company with which they hold a policy’.
We also spoke to Jose Domingo Valls Lloret, secretary of Gestitursa, who emphasised: “Not one Spanish public hospital or hospital concertado refuses the EHIC to a single patient that presents it.” However, explaining that the hospitals have the right to give patients a choice of whether to use their EHICs or private insurance, Valls Lloret added: “Based on the principle of equal treatment, foreign patients are subject to the application of article 83 and others of the Health Act, by which the Spanish Public Health System reserves the right to claim payment of medical costs from a third party (insurance or assistance companies) which have the legal obligation to pay.”
Whatever the case, both the EC and the UK Foreign and Commonwealth Office (FCO) told us that the situation is on their radar. An FCO spokesperson commented: “Both the FCO and the Department of Health are aware of cases in Spain where customers have been asked to provide travel insurance instead of their EHIC. We have raised the issue directly with central government and with the European Commission. We have also heard of anecdotal evidence of customers being asked to pay up front for treatment if an EHIC could not be produced at the time of receiving care in a state facility.”
Speaking for the EC, Jonathan Todd, spokesman for employment, social affairs and inclusion, told ITIJ: “The Commission is aware that there are some problems in Spain as regards the alleged refusal of some hospitals to recognise the EHIC. Spanish public hospitals – and hospitals concertados – have to accept the EHIC. The Commission is currently in discussions with the Spanish authorities in order to resolve these problems.”
Help (un)available
To go back to basics, let’s remember the tourist on holiday, with a medical emergency, who wants to get treated under the EHIC. Having read the standard advice, they know they have to go to a public hospital, not a private one. Imagine there’s a hospital concertado next door – will they accept the EHIC? From our research, this simple information is not easy to obtain.
For example, to go back to the hospital we called, the information we were given during the phone call is different from what we were told when we asked a spokesperson for a formal explanation of the hospital’s official policy. We were told that the hospital ‘treats, with no charge to the patient, any European citizen that has an EHIC’. If a patient has been refused this right, which the hospital said it doubts, it must have been an ‘internal administrative error’. Patients at the facility may, of course, choose to pay via their private insurance instead, in which case they would sign a document written in their own native language, said the hospital.
Who else could confirm quickly which local hospitals do or do not accept the EHIC? A spokesperson for the MSSSI said that it does not hold this information, as the hospitales concertados operate under many different contract models, and the authorities in the relevant autonomous community should be contacted for information. Having both time and a reasonable command of Spanish, luxuries that a tourist may not have, we tried to find out if the hospital we called should accept the EHIC by asking the department of health of the autonomous community in which it was based, but we were told to refer to a more local health authority. The director of the local authority told us simply: “[The EHIC] is accepted in all hospitals that comprise the health system, including public hospitals and hospitales concertados.”
Perhaps the authorities in the person’s native country could help? Given that our example was a British traveller, we contacted the Department for Health and the UK Foreign and Commonwealth Office (FCO). However, neither could do more than repeat the general advice that the EHIC can be used in public hospitals but not private ones. The EC was (slightly) more forthcoming: asked what a tourist who is unhappy or confused by what a hospital is telling them should do, Todd told us that in case of complaint, travellers should contact the ministry of health in the region in which the hospital is based. If that fails, he said, then they should go to the national ministry of health (in this case the MSSSI), or to the body that issued the EHIC in their home country.
There is one other port of call – local consulates. For UK travellers, the FCO advises that they can report any incidents to representatives of the Department for Health, who are based at consulates in Spain. We tried several times to reach the consulate teams, but were unable to get a response.
As a final resort, if the patient has paid for care out of their own pocket, they can claim reimbursement from their national health insurance provider after they return home, as the EC website explains. However, there is a warning that costs incurred for ‘private treatment’ are not refundable.
Conclusion
You’ve got to feel sorry for sick travellers in Spain. It seems, from the allegations passed to us by the travel insurance industry, from the phone call we have transcribed, and from the comments of the FCO and EC, that in some cases at least, tourists are having their EHIC refused as a method of payment when they expected it to be accepted. If they want to check their rights, the information available online from the EC is limited, and no one we spoke to was able to give advice on hospitales concertados other than a local health authority and an EC spokesperson – both channels would be difficult for a tourist in distress to access. The international department of the hospital we called told us the EHIC cannot be used by in-patients, but the management’s statement suggests it can, so even speaking to the hospital involved may not clear up the confusion.
It’s possible that the stories policyholders are telling their insurers and assistance companies relating to the EHIC are made-up and don’t reflect the reality. But if they are true, and if the conversation we had with that international department was not simply an ‘administrative error’, then something must be done. If the EC believes that the EHIC must be accepted in all public hospitals – including concertados – it needs to update its advice to say so. And if it believes that in some cases, the EHIC is being refused – perhaps against the hospital’s stated official policy – it must take action to enforce the rules.
In the meantime, all we can say to travellers is ‘good luck’.
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No EHICs for in-patients
The following is a transcript produced from a recording of a conversation that ITIJ held with a Spanish hospital (in this case a ‘hospital concertado’), which we cannot name for legal reasons.
The caller advised the receptionist he was on holiday and his wife felt unwell – he was first passed to the emergency department, who passed him on to the ‘translation service’ at the ‘international department’. Parts of this transcript are a translation from Spanish.
ITIJ: Buenas dias. We are here on holiday and my wife feels unwell and I’m not sure what to do. I would like to ask if we have to pay or how it works.
International department (ID):
It depends. Where are you from?
ITIJ: We’re from England.
ID: England. And what insurance do you have? Do you have travel insurance or anything?
ITIJ: Yes, we have travel insurance. I’m not sure where the documents are. We also have the European Union health card; I have it here.
ID: OK, it’s that normally, the procedure with foreign patients that are ‘in-patients’ are taken care of by their travel insurers. But if it’s an ‘out-patient’ that only go by ambulance and that’s why they have to pay – asking about the reimbursement, we prepare all the documents at once, and you can send them from here to the insurer, and they will pay on your behalf.
ITIJ: Again – if it’s an in-patient…
ID: If it’s an in-patient, if you should stay in the hospital, normally it’s an insurance company that takes care of [the] charge. If it’s only out-patient, then normally they ask us to charge the patient and give you all the papers to ask for a refund in your country.
ITIJ: OK. The thing is I’ve got the European Health Insurance Card, so if I bring that with us, is that OK?
ID: Well, normally if you have travel insurance or something, the law is that they are supposed to pay.
ITIJ: Oh, OK.
ID: You know, I mean, because you are paying through – it cannot be charged through social security, it has to be charged through private insurance.
ITIJ: OK. It’s just that I have the card in my wallet, but the travel insurance documents – I’d have to look for them, because it’s my wife that normally deals with that sort of thing, so I’d have to go through the suitcases or something. Is it worth me doing that, does it make a difference?
ID: In any case I will have to charge you, give you a bill, and you will have to ask for a refund.
ITIJ: Oh, OK, so we can’t just bring the card?
ID: Just bring the passport, it will be the most important. I will give you some papers to [fill out], and then we will proceed. If you give me your insurance [details] I will know how to involve with them.
ITIJ: If it’s, I mean, the European card thing, I thought it was, if it’s, an emergency (I don’t know if it is an emergency, I don’t know what’s wrong with her) isn’t that covered by the card?
ID: No, as I told you, a third-party is always taking the charge in these cases. [indistinct] All the hospitals they [charge] the private insurance companies.
ITIJ: OK, so I guess I need to look for those insurance documents in case she’s an in-patient. I hope she’s not –
ID: Don’t you worry about it. If she feels bad, don’t you worry, just come by with [a] passport and as I told you, you give me your home address and everything and then we’ll go through the administrative things, OK?
ITIJ: OK, I’ll call a taxi in that case.
ID: Okey doke. We’ll see you in a moment then.
ITIJ: Thank you.
ID: Bye bye.
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When is a public hospital not a public hospital?
FROM JOSE AFONSO, ONE Assist:
A ‘Hospital Concertado’ applies to PRIVATE hospitals that also accept public patients through collective agreements with the NHS.
(It is so that if the local NHS hospital is full or is not suitably equipped to provide a treatment, the NHS will pay a private hospital to accept the overflow or treat that patient. The cost is then met by the NHS.)
From our understanding, to receive ‘free’ treatment as an NHS patient in a private hospital (concertado) a patient must have been referred by an NHS hospital. One cannot walk into a [private] hospital and demand to be treated as an NHS patient. And that applies to whether you have an EHIC or not.
FROM MARIA REALES, Gestitursa:
It is the case that NHS in Spain is quite complicated and there are different types of ‘public hospitals’ (at least in the Catalan Autonomous Region) – those that are strictly public and belong to the ICS (Institut Català de Salut/Catalan Health Institute)
and those that are run privately but financed with public funds and belong to the XHUP (Red hospitalaria de utilización pública).
I think this precision doesn’t make any difference in relation to the EHIC use. It is basically a management issue.