Game Over?

It’s been seven months now since the European Commission (EC) became involved in discussions surrounding the refusal of European Health Insurance Cards (EHIC) by some hospitals providing public healthcare services to European citizens. While the incidence of EHIC refusals appears to have dropped significantly in Spain, elsewhere the issue of third-party administrators managing foreign patients in popular tourist resorts remains. Mandy Langfield looks at the current status quo

The issue of EHIC refusal first reared its head in Spain, where a significant number of public hospitals and private hospitals contracted to provide public healthcare, through their involvement with third-party private management companies, began to refuse the EHIC and instead bill the patient’s travel insurer for medical  treatment received, claiming that this was justified under Spanish law as the travel insurer is a ‘third party liable to pay’. However, following a concerted effort by European travel insurers, legal entities working on their behalf, the European Commission, and the Spanish authorities, along with investigations by ITIJ, the issue of EHIC refusal is declining. The private management companies are, by and large, running for the hills, although they maintain their presence in certain hospitals in certain areas – oddly enough, in regions that receive a significant number of tourists. Eric Grootmeijer, network manager for Dutch insurance and assistance  provider ANWB Assistance, said that from his contact with hospitals and clinics in Europe, seven hospitals in Spain and four in Portugal have terminated their contracts with Gestitursa, one of the management companies involved in the collection of funds from patients and insurers. “Our information, however,” continued Grootmeijer, “shows that Gestitursa is still active in three public hospitals in the Barcelona region and two in Portugal.” Grootmeijer went on to say: “Two hospitals in Funchal, Madeira, are believed to have contact with Tourisalus, another third-party administrator.” The ways and means in which Tourisalus operates, though, seem to be less ‘aggressive’ than other companies, he noted. Ian Jones, lifestyle claims technical manager for AXA Insurance in the UK agreed that there is a more reasoned approach from Tourisalus, and it is clear from what David Pennington, head of the international healthcare for the UK Department of Health, said at the International Travel and Health Insurance Conference in Vienna at the end of 2013, that Portuguese authorities are not keen on receiving the same kind of publicity as that seen endured by Spain in 2013, when news articles about the issue of EHICs being refused by Spanish hospitals were published widely.

providers of travel insurance are not getting nearly as many bills from medical providers or third-party administrators seeking payment in lieu of accepting the EHIC

Status quo

Currently, it seems that providers of travel insurance are not getting nearly as many bills from medical providers or third-party administrators seeking payment in lieu of accepting the EHIC. According to Ian Jones of AXA Insurance, “There have been minimal issues here [in the UK], and where there has been a challenge, it has been resolved quite promptly by using the letters the EC sent out to show the providers the error of their ways.” However, Gestitursa, he said, remains in the picture: “We have seen some further billing from Gestitursa, and this has been in the form of legal action. These writs have been on old, low-value cases though, nothing on anything post-EC infringement proceedings.” Considering the potential for the same problem to rear its head in Portugal, Jones said: “This does not seem to be the issue we feared. [We are] keeping a close eye on it, particularly for the retired customers over there for a couple of months. We will be watching next summer closely.”

In January 2014, it was reported by sources in the industry that the company’s office in Spain was ‘under pressure’, although according to the company’s website – which has made the change from FundacionGestitursa to Hospiquality, the name under which Gestitursa operates in certain countries – it continues to work on behalf of several hospitals in Barcelona and Madrid, as well as the Clinica Bofill in Girona in Spain. In Portugal, the company appears to still be in operation in hospitals in Cascais and Setubal. Maria Ana Lopes, marketing and communications spokesperson for HPP Saude, the Portuguese private hospital group that runs the public hospital in Cascais, has confirmed to ITIJ that it continues to work in partnership with Gestitursa.

ITIJ also spoke to Doruk Baglan, division manager for Turkish company Marmassistance, who explained the chain of events that saw Gestitursa become Gestiturksa. According to Baglan, Gestitursa had been operational throughout 2013, working in Turkish public hospitals as Gestiturksa, where it was involved with the management of foreign patients on behalf of these hospitals. However, as Gestiturksa was not a licensed medical provider in Turkey, there were obstacles on the pathway to successful operations in the country – an 18-per-cent value added tax (VAT) rate had to be added to invoices the company was sending out, which increased the amount payable by quite some margin. Furthermore, because of the lack of a licence, international insurance and assistance companies were not able to issue guarantee of payment letters to the company – they could only issue such letters to the hospital. Baglan added: “The Ministry of Health was not fully  aware [of the situation] and through the combined efforts of local and international assistance and insurance companies, the Turkish Ministry of Health commissioned investigators to the hospitals with Gestiturksa connections.” As of the fourth quarter of last year, he continued, Gestiturksa’s operations in Turkey had been suspended. “Although no official written release was published regarding their termination, trusted sources in the Ministry of Health have declared that Gestiturksa no longer has any effect in the billing management of foreign-insured patients in Turkish hospitals,” concluded Baglan. Christina Bring Nielson, network  co-ordinator for Denmark-based SOS International, confirmed to ITIJ that the company has not received any new cases lately from Gestitursa in Spain, Portugal or Turkey, although she was keen to point out that the issue has not completely disappeared: “We cannot promise that no new cases will appear.”

because of the lack of a licence, international insurance and assistance companies were not able to issue guarantee of payment letters to the company

Similarly in the UK, those in the industry remain cautiously optimistic. David Pennington told ITIJ: “We have not been alerted to any major instances of [EHIC] refusal since the European Commission proceedings and subsequent agreement that the Spanish Health Ministry notified to their regions. Things have subsided, which is very positive and hopeful, and testament to the collective actions taken by the Commission, Spanish government and ourselves, althoughwe will be alert to any further change, in particular as the new tourist season ramps up.” Gillian More, legal officer and director general of Employment, Social Affairs and Inclusion for the European Commission, confirmed: “Since Spain issued new guidance on the use of the EHIC last July, I have not received any more reports of Gestitursa sending bills to EU tourists directly, nor of complaints of the EHIC being refused where the holder also had travel insurance.”

As of the fourth quarter of last year ... Gestiturksa’s operations in Turkey had been suspended

Moving forward as one

There is no doubt that part of what made the EC sit up and take notice of the problem was that, for once, the European travel insurance industry displayed a united front, with information sharing and legal opinions coming together to form one, strong defence. Could this be a sign of things to come for the industry when new problems rear their heads? Jones of AXA Insurance certainly hopes so: “We have worked together so well over this it would be a shame to lose momentum. I would like to see us being more collaborative on tackling providers that are robbing us blind with overcharging and fake billing for treatment. We try to tackle these issues through our own cost containment programmes, but I wonder how successful we would be if we collectively turned off the tap to some of these places.”

Although ITIJ attempted to contact Gestitursa in a number of different ways for comment for this article, it received no response.