Annexes to COM(2021)92 - Use of travel medical insurance, under Article 15 of Regulation (EC) No 810/2009, by visa holders during their stay in the territory of the Member States - Main contents
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This page contains a limited version of this dossier in the EU Monitor.
| dossier | COM(2021)92 - Use of travel medical insurance, under Article 15 of Regulation (EC) No 810/2009, by visa holders during their stay in the ... |
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| document | COM(2021)92  |
| date | March 2, 2021 |
-Checks on the possession of insurance by health institutions
Holding an insurance is not a precondition for receiving medical treatment. However, most EU Member States note that depending on the patient’s condition upon admission, medical institutions may require insurance before treatment but there is no uniform approach in place. In most cases, the patient is requested to show such proof after the treatment or to pay directly the hospital or, the later charges the insurer.
Some EU Member States’ medical institutions require a down payment by the patient (e.g. amounts of 300 EUR or less) making insurance recovery irrelevant. Others require all non-EU residents or, if relevant, an inviting person/sponsor, to pay the treatment directly.
-Lack of data to determine if visa holders use their insurance
When collecting patients’ personal data, information on their nationality may also be collected. The conditions of stay (i.e. whether the individual holds a visa or a residence permit) of people who have been treated are not collected centrally, but may be kept at hospital or regional level. Some EU Member States have carried out ad hoc surveys on non-EU nationals having received medical treatment, but without distinguishing between conditions of stay or coverage of bilateral agreements on medical treatment.
Three EU Member States have indicated that random checks are conducted at the external borders to check if visa holders hold a valid insurance. One of the three indicates that absence of an insurance policy may lead to revoking the visa on the ground that one of the conditions for granting the visa is no longer met.
-Recovery of unpaid medical bills
No EU Member State appears to apply cross-cutting rules or guidelines for recovery of unpaid hospital bills. This is also due to the decentralised set up of healthcare in most EU Member States that leaves it to the individual institution to set its own practice.
All EU Member States confirm that recovery from individuals or insurance companies abroad is extremely challenging (time consuming and costly).
In some EU Member States, national ‘re-insurers’ exist in the form of public agencies under the ministry of health that cover hospitals’ costs for unpaid bills but has no means to seek recovery from the patient or the insurer.
Several EU Member States indicate estimates of unpaid medical bills for treating foreign nationals (without distinction of nationality) ranging from 10% to 60%, but only one shared data on unpaid medical bills specifically by short stay visa holders from one region of the country (65%). That EU Member State also indicates that the rate for unpaid medical bills for non-EU nationals that may travel visa free (and free of insurance) to the EU is 62%. Against this background, it is difficult to argue that the requirement makes a real difference.
2.Current situation: no clear picture
There are considerable differences in the experiences between EU Member States, due mainly to the differences in healthcare systems. Urgent medical treatment is offered universally and covering the cost is a secondary matter. In some EU Member States, bilateral healthcare agreements with non-EU countries cover medical treatment regardless of whether the individual concerned holds insurance or not. Situations also differ depending on whether healthcare takes place under a private commercial ‘contract,’ is provided directly by state institutions or, a mix of the two where the state is the ‘re-insurer.’ EU Member States’ estimates of the amounts that unpaid medical bills represent vary widely. Some EU Member States judge that the problem is insignificant, stating that ‘visa holders pay their medical expenses,’ without providing evidence. Others consider this to be a matter of major concern noting the coverage threshold of EUR 30000 is insufficient.
As possession of an insurance is not an entry condition and therefore not checked upon entry, there is no evidence that visa holders hold the appropriate insurance each time they travel.
Furthermore, precise data collection on unpaid bills by short stay visas holders is difficult and appears non-existing. So, the reasons for unpaid bills (incurred by non-EU nationals) remain unknown and clarity is needed on a number of aspects, such as:
-What is the share of short stay visa holders in need of urgent medical treatment during their stay that do not hold any insurance or hold insufficient insurance?
-Can insufficient insurance cover be explained by the fact that the current legal basis does not clearly spell out the requirements for an insurance to be considered adequate?
-Is the level of coverage (EUR 30 000) too low to cover all costs?
-What are the reasons for insurance companies’ refusal to cover incurred medical costs?
-Why do medical institutions not seek recovery? Is it because of the low success rate or because in the end the central authorities cover the debts?
An additional but significant issue is that there is no evidence that visa required non-EU nationals present different problems for healthcare compared to non-EU nationals who may travel visa free to the EU 8 (see above). It is therefore highly questionable whether the different requirements between these categories of travellers are justified.
In their replies, some EU Member States argue that the requirement should also be seen as a means of protecting travellers in case they would need urgent medical treatment during their stay. However, this concern should apply to all non-EU nationals travelling to the EU.
3.Impact of the COVID-19 pandemic
The COVID-19 pandemic and the ensuing worldwide travel restrictions put a sudden, almost complete stop to visa operations from end March 2020 and a high number of visa holders present in EU Member States who were unable to leave by the expiry of their visa. The pandemic further highlighted the pressing need to evaluate the effectiveness of insurance and the following questions were put to Member States:
-What is the impact of the current COVID-19 pandemic? Have you noticed any changes in unpaid healthcare bills during this period? If such data are not available yet, you should indicate when they will be.
-What are the provisions on health insurance and medical care that apply to holders of short-stay visas who have to remain in the Schengen area for longer than 90 days because of the COVID-19 pandemic?
EU Member States’ replies to these questions were very similar: it is too early to determine whether the pandemic has had an impact, but the low numbers of non-EU national travellers (‘visa free’ or ‘visa required’) suggest that there will be no impact. Most EU Member States did not require involuntary ‘overstayers’ to take out insurance for their extended stay and any emergency treatment was given during that period. People in need of other types of medical treatment during their extended stay would have to cover the costs themselves.
By November 2020, EU Member States restarted to process the low-levels of visa applications around the world, and an insurance-related aspect directly linked to the COVID-19 pandemic has emerged. Spot checks carried out in April 2020 show that several major insurance companies are now offering insurance policies containing specific clauses that exclude medical costs linked to an epidemic or pandemic outbreak from coverage, or cover them only in part. Similar trends have also been reported by EU Member States consulates.
III.Next steps
The picture is not conclusive as to the efficiency of the current insurance requirement. This report shows that relevant and solid data are missing that would allow the Commission to fully assess the efficiency of the current rules. There is, however, ample evidence of the challenges for different actors in the implementation of the measures and the following conclusions can already be drawn:
1)There is no evidence to suggest that the current insurance requirement provides a significant relief for healthcare systems by ensuring payment of treatment because the problem of unpaid bills remains. Additionally recovery of unpaid hospital bills appears to be a considerable problem, even in cases where the patient holds an insurance at the moment of the treatment.
2)The following weaknesses in the way the current requirement is designed can be identified:
-The timing of the presentation of proof (upon lodging the visa application).
-The broad, unclear and possibly outdated rules on insurance coverage, therefore making it difficult for consular staff to check that the insurance is compliant.
-Actual possession of insurance is not checked when the visa holder crosses the EU border.
3)The information provided by EU Member States indicates that the absence of equivalent requirements for visa-free travellers could be part of the problem of unpaid hospital bills as there is no evidence that visa required non-EU nationals present different problems for healthcare compared to non-EU nationals who may travel visa free to the EU.
Several options for follow-up action could be envisaged:
-Accept the current situation without any real evidence of benefits for health systems despite the known problems for visa applicants, the challenge for consulates, the embedded structural problems and the lack of data available that would allow an assessment of whether the insurance requirement is actually applied as intended.
-Acknowledge that the legal basis is outdated (drawn up 17 years ago) and must be improved to ensure that it serves the intended purpose, namely that visa holders hold an adequate insurance during their stay, for example, by defining precise policy requirements that insurers must refer to explicitly in their policy (‘Guaranteed EU travel medical insurance minimum standard’). Provisions could include standard payment procedures to ensure recovery of costs; the possibility of extended coverage in case of stays beyond the expiry of the visa due to prolonged treatment; and the possibility of continuous coverage for holders of multiple entry visas (‘pay as you go’). A ‘guarantee label’ could also, particularly when the visa procedure becomes fully digitalised, enable consulates’ ability to check that the insurance policies presented by visa applicants comply with the legal requirement.
-Recognise the fact that there should be no different treatment between visa-required and visa-free non-EU nationals for insurance coverage during their stay in the EU and consider extending the insurance requirement to visa-free travellers, while ensuring that compliance is checked at the appropriate moment (i.e. when travel takes place).
To seek clarity on the efficiency of the insurance requirement and of the possible need for a revision of the legal basis, the Commission intends, building upon this report, to launch a study to collect additional data.
(1)
Council Decision of 22 December 2003 amending Part V, point 1.4, of the Common Consular Instructions and Part I, point 4.1.2 of the Common Manual as regards inclusion of the requirement to be in possession of travel medical insurance as one of the supporting documents for the grant of a uniform entry visa (2004/17/EC), OJ L 5, 9.1.2004, p. 79.
(2)
Regulation (EC) No 810/2009 of the European Parliament and of the Council of 13 July 2009 establishing a Community Code on Visas (Visa Code),OJ L 243, 15.9.2009, p. 1.
(3)
Article 6(1)) of Regulation(EU) 2016/399 of the European Parliament and of the Council of 9 March 2016 on a Union Code on the rules governing the movement of persons across borders (Schengen Borders Code), OJ L 77, 23.3.2016, p. 1.
(4)
European Travel Information and Authorisation System.
Regulation (EU) 2018/1240 of the European Parliament and of the Council of 12 September 2018 establishing a European Travel Information and Authorisation System (ETIAS) and amending Regulations (EU) No 1077/2011, (EU) No 515/2014, (EU) 2016/399, (EU) 2016/1624 and (EU) 2017/2226, OJ L 236, 19.9.2018, p 1.
(5)
SWD (2014) 101 final.
(6)
Regulation (EU) 2019/1155 of the European Parliament and of the Council of 20 June 2019 amending Regulation (EC) No 810/2009 establishing a Community Code on Visas (Visa Code), OJ L 188, 12.7.2019, p. 25.
(7)
Period of allowed stay: the number of days that the visa holder is allowed to stay, e.g. 30 days.
Period of validity of the visa: a period of 15 days is added to the period of allowed stay to allow the visa holder flexibility in using the visa (plans or flights may changes etc.), meaning that a person may hold a visa valid for 45 days, allowing for a stay of 30 days. The travel medical insurance is to cover a period of 30 days.
(8)
In 2019, around 15 million short stay visas were issued and of these more than 50% were multiple entry visas. By comparison the report on the ‘Technical Study on Smart Borders’ concluded that the indications for expected traffic at external borders in 2020 for “visa free” non-EU nationals would be 104 million.