Background
On August 6, 2019, Mme [R], then residing in France and insured under the French social-security system, asked the Haute-Savoie primary health insurance fund to cover planned outpatient psychiatric and psychotherapy treatment provided by a specialist in Switzerland. The fund refused, stating that it covered only urgent and medically necessary care received in Switzerland.
Mme [R] challenged that decision before the social-security courts. The Grenoble Court of Appeal rejected her claim, reasoning that outpatient consultations in a medical office did not qualify as planned care covered under Regulation (EC) No. 883/2004. It also applied Article R. 160-2 of the French Social Security Code and concluded that the treatment involved neither an overnight hospital stay nor highly specialized and costly medical infrastructure or equipment.
The Court’s Holding
The Court of Cassation quashed the appellate judgment in full. It held that a person insured under the French social-security system who travels to Switzerland for planned care other than treatment requiring an overnight hospital stay or highly specialized and costly medical infrastructure or equipment may obtain reimbursement, provided that the person follows the authorization procedure and satisfies Article 20 of Regulation No. 883/2004.
Under Article 20, authorization must be granted when the treatment is among the benefits provided by the law of the insured person’s state of residence and cannot be provided there within a medically acceptable time, considering the person’s current health and the probable course of the illness. Article R. 160-2 governs specified hospital-based or highly specialized care but does not govern other care provided in Switzerland. The Grenoble court therefore erred by refusing to apply Article 20 and by applying Article R. 160-2 to the outpatient treatment. The Court of Cassation did not itself award reimbursement; it remanded the case to the Lyon Court of Appeal for further proceedings.
Key Takeaways
- Planned outpatient care received in Switzerland is not categorically excluded from reimbursement under Regulation No. 883/2004.
- For care outside the categories covered by Article R. 160-2, eligibility turns on compliance with Article 20’s authorization procedure and substantive conditions.
- The ruling establishes the applicable legal framework but leaves the Lyon Court of Appeal to determine whether Mme [R] actually satisfies the requirements for reimbursement.
Why It Matters
The decision prevents French health insurance authorities and courts from treating the limited categories in Article R. 160-2 as the exclusive basis for covering planned treatment in Switzerland. It confirms that EU social-security coordination rules, extended to France-Switzerland relations, can also govern ordinary outpatient care.
For insured patients and practitioners, the ruling makes clear that the decisive questions are whether the treatment is covered in the state of residence, whether it could be obtained there within a medically acceptable time, and whether the required authorization procedure was followed—not merely whether the care involved hospitalization or costly specialized equipment.