Joint Sickness Insurance Scheme complementary cover for dependants with outside primary cover

• PURPOSE
• PERSONS ENTITLED TO COMPLEMENTARY COVER FROM THE JSIS
• ARRANGEMENTS
• REIMBURSEMENTS
  

1. PURPOSE
   
   This administrative notice is only concerned with spouses/ recognised partners who benefit from complementary reimbursements and children insured through a primary sickness insurance. The aim of this publication is to clarify as well as remind you, on the basis of the rules and procedures in force governing the JSIS, how and on what conditions the JSIS will provide complementary cover where primary cover is provided by another scheme.
    
2. PERSONS ENTITLED TO COMPLEMENTARY COVER FROM THE JSIS
   
   2.1. Members’ spouses/ recognised partners with outside primary cover
   
   Spouses/recognised partners who are gainfully employed or in receipt of income deriving from previous gainful employment (retirement or invalidity pension, unemployment benefit, maternity...) provided:
    
   • their annual income before tax does not exceed the basic annual salary of an official in Grade AST2/1⁽¹⁾ ;
      
   • they have primary cover against the same risks as those covered by the JSIS under another sickness insurance scheme.

   2.2. Members’ dependent children with primary cover via the parent in a national scheme
   
   Dependent children where the spouse’s/partner's scheme agrees to provide primary cover with no extra contribution.
    

3. ARRANGEMENTS
   
   Free choice of doctor and hospital or clinic
   
   Members’ spouse/recognised partner and children with primary cover from an outside scheme must first apply to that scheme for the reimbursement of medical expenses as the JSIS provides only complementary cover for them.
   
   However, our scheme will provide primary cover for certain items not covered by an outside scheme, provided there is no doubt that they are both medically necessary and functional (e.g. spectacles, dental prostheses, etc.).
   
   Dependent spouses and children must complete the formalities required by their outside primary health insurance scheme. National schemes generally lay down precise rules and/or restrictions regarding the choice of doctor or medical establishment, e.g. reimbursement for the public sector only or special conditions for treatment abroad. It is therefore recommended that they find out from their primary scheme about the procedures to be followed.
   For instance they may be required to use the European Health Insurance Card (which replaces the E111 form) for emergency treatment in another Member State (including Norway, Liechtenstein, Switzerland and Iceland); prior authorisation may have to be obtained for planned (non-urgent) treatment in another Member State, and so on.
   
   It should be noted that following several cases which were taken to the European Court of Justice (Kohll, Decker, Smits-Peerbooms, Müller-Fauré-van Riet⁽²⁾), national sickness schemes are obliged to reimburse all treatments (with the exception of hospital treatment) carried out in all European Union countries, without needing to ask for prior authorisation. However, in these cases, the bill must indicate exactly what treatment was carried out to enable the national scheme to identify it according to its list of treatments. It is also essential that the treatment concerned is reimbursable under the national scheme’s rules and that all conditions to obtain reimbursement for it have been fulfilled. For example, it could happen that the national scheme refuses to reimburse a visit to a specialist abroad because under the national rules it was first essential to obtain a referral from a general practitioner
   
   If the exercise of freedom of choice means that reimbursement from the outside scheme is impossible, our scheme will provide primary cover in the following cases.
    
   • For spouses/recognised partners with JSIS complementary cover, who claim they are not entitled to any reimbursement under their primary health insurance scheme for a hospital stay abroad or in a private clinic (in countries with national health services, such as the United Kingdom and Italy), the JSIS will reimburse as the primary sickness scheme in certain cases (namely waiting lists, emergencies and similar circumstances):
      
     • where the procedures laid down by the primary health insurance scheme have been complied with and
        
     • on production of a reasoned statement by the primary scheme or national health service.
        
   • For children with primary cover from an outside scheme the JSIS will continue to act as the primary scheme for treatment received abroad or privately (in countries with a national health service) whatever the reason for the refusal of the external primary scheme to reimburse. This means that the JSIS does not require the procedures of the external primary scheme to have been complied with: you need only provide proof that the outside primary scheme has refused to reimburse the expenses.

   You are reminded that dependants qualifying for complementary cover from the JSIS are not entitled to direct billing (prise en charge) to the JSIS of hospitalisation expenses. They must apply to their primary scheme. However, direct billing to the JSIS may be possible in exceptional cases, provided we have agreed in advance to act as primary insurer.
    

4. REIMBURSEMENTS
    
   • For some treatment (e.g. orthodontic treatment, dental prostheses, etc.) prior authorisation must be obtained or an estimate submitted. Dependants qualifying for our complementary cover must always request authorisation in the first instance from their primary scheme. If that request is accepted, there is no need to submit a prior authorisation application to the JSIS.
      
   • Make sure that when receipts or certificates of services provided are issued certain details which are not required by the primary health insurance scheme are included, e.g. a breakdown of fees for individual treatments.
      
   • Before submitting medical claims to the primary health insurance scheme, photocopy all the relevant documents.
      
   • Claims for reimbursement from the JSIS should be made on the normal form.
      
     • Where partial reimbursement by the outside scheme has already been made, copies of the bills (receipted or with proof of payment) and the original of the statement of reimbursements issued by the outside scheme must be attached.
       In the case of some items, the patient pays only part of the full cost (ticket modérateur). In such cases, the full cost and the reimbursement received from the outside scheme must also be indicated, not just the actual cost to the patient. For instance, for medicines the pharmacist must indicate the full price and the price actually paid.
       Only the difference, if any, between the amount reimbursed by the outside scheme and the amount covered by our scheme will be paid, subject in all cases to our ceilings.
        
     • Where our scheme is acting as the primary scheme, the original receipted bill (with the indication of the reason why it has been refused by the outside scheme) must be attached to the claim.

Footnotes
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⁽¹⁾ For the period from 1 May 2004 to 30 April 2006: grade C*2, step 1

⁽²⁾ C-120/95 (Kohll), C-158/96 (Decker), C-157/99 (Smits-Peerbooms), C-385/99 (Müller – Fauré-van Riet)