Understanding the European Health Insurance Card

Expat Briefing Editorial Team, 13 June, 2013

Many travellers and expatriates in the European Union (EU) think that holding the European Health Insurance Card (EHIC for short) will automatically entitle them to free medical treatment should they fall ill or have an accident while visiting another EU country. In many cases this is true. But the "insurance" element provided via the EHIC is limited – especially for expats – and it is crucial to understand just what it does and does not cover.

Why Has The EHIC Been In The News Lately?

The EHIC is not publicised as heavily as it should be by national health authorities in some Member States – there is a common misconception in the United Kingdom for example that its predecessor, the E111, is still in existence (it was replaced by the current health insurance card in 2005). The EHIC nevertheless hit the headlines recently when it emerged that Spain had denied EU citizens free access to medical treatment even though they were legally entitled to it with their EHIC.

In one sense, the actions of the Spanish health authorities are understandable. The Government is desperately trying the pull the country out of the Eurozone crisis, and the last thing it wants to do is spend billions of euros treating foreign nationals in its public healthcare system. However, the country is clearly breaking the law, and the EU is finally stepping in to do something about it.

On May 30 the European Commission announced that it has requested information from Spain about complaints that Spanish hospitals providing public healthcare are refusing to recognise the EHIC. The Commission is concerned that Spain might be failing to fulfil its obligations under EU law to provide emergency healthcare to temporary visitors from other Member States on the same terms and conditions as are available to Spanish nationals under the public healthcare scheme (see below for outline of the EHIC rules).

The Commission’s request for information follows an increasing number of complaints it has received concerning hospitals providing public healthcare services, mainly in tourist areas of Spain, which refuse to treat citizens on the basis of their European Health Insurance Card and instead request a travel insurance policy and credit card details.

Public healthcare is generally free of charge in Spain and the EHIC entitles its holder to be treated on the same terms as Spanish nationals. However, in some cases, citizens have been erroneously informed that their EHICis not valid if they have travel insurance. Other patients believed they were being treated on the basis of their European Health Insurance Card, but later found out that their travel insurance company had been sent a bill for treatment.

The actions of the hospitals concerned means that European Health Insurance Card holders are being denied access to public healthcare on the same terms as Spanish nationals, and are being offered only private treatment. The much higher cost of such private treatment is being passed on to the travel insurance companies or, increasingly, is being billed to the citizens directly. The travel insurance industry has underlined to the European Commission that in most cases travel insurance will not cover private healthcare.

The European Commission says it has been in contact with the Spanish authorities regarding this issue since 2010. The Spanish authorities have indicated to the Commission that they have taken certain actions to tackle the issue. Nonetheless, the Commission continues to receive complaints about this practice by hospitals providing public healthcare services in tourist areas.

What Exactly Is The EHIC?

The EHIC certifies that the holder has the right to receive emergency healthcare during a temporary stay in any EU country as well as Switzerland, Liechtenstein, Norway and Iceland. This right is guaranteed to all persons who are covered by the public healthcare system of these countries. The EHIC holder has the right to receive necessary treatment in the host Member State's public healthcare system on the same terms and at the same cost as nationals of the state concerned. The cards are issued free of charge by local health authorities, but the duration of their validity varies from one EU Member State to another; in the United Kingdom for example, they must be renewed every five years. Each separate member of a family travelling within the EU and the above named countries should have their own card.

Individuals from non-EU countries who are legally residing in the EU and are covered by a state social security scheme are also eligible for a card. However, nationals from non-EU countries cannot use their EHIC for medical treatment in Denmark, Iceland, Liechtenstein, Norway and Switzerland.

If you ask for the EHIC, your local health authority is obliged to provide you with one or, failing that, with a provisional replacement certificate if the card is not immediately available.

Where citizens require healthcare, but do not have an EHIC, or don't have it with them, they can also request a Provisional Replacement Certificate (PRC) from the relevant health body in their home Member State and this can usually be faxed or e-mailed to them. The PRC will show that they are entitled to benefit in the host country from the right to necessary healthcare given by EU law and can be used in the same way as a European Health Insurance Card. The aim is to prevent citizens having to return home before the end of the planned duration of stay.

What Does the EHIC Cover?

Health systems vary from country to country within the EU and there is no standard EHIC procedure as such should you need medical assistance. Therefore, it is important to know where to go if you fall ill so that you are not hit unexpectedly hard in the wallet. The European Commission has a website which explains how to obtain medical treatment in the 31 countries covered by the card, and the following sections details its advice if you require the services of a doctor, dentist or a hospital in Spain.

Treatment and Costs

Before you consult a doctor or a hospital, make sure that they are part of the Public Healthcare System, so they accept your European Health Insurance card. Some hospitals and health centres (centro sanitario) offer both private and state-provided healthcare and it is up to you to inform them, which services you require. Any costs incurred for private healthcare are non-refundable and not covered by your card.


State-provided healthcare is free of charge. Be aware that hotels and tour operators can sometimes call or recommend a private doctor who will charge you.

If you need to call out a doctor in an emergency, make sure you have a valid European Health Insurance Card and ask for state funded healthcare.

If you are asked to pay up front, you are not being treated under the Spanish health service and your European Health Insurance Card will not be accepted.


Dental treatment is generally not available under the state system and the costs are not refundable.

Hospital Treatment

You will need a doctor's referral for any hospital treatment, except in emergencies.

Only 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.


Medicines prescribed by health service practitioners can be obtained from any pharmacy.

You will be charged up to a certain percentage except in some cases if you are a pensioner from an EU country, Iceland, Lichtenstein, Norway or Switzerland, which you must be able to prove. This is non-refundable in Spain but you may be able to seek reimbursement when you are back home.

If you are told by a hospital that you require medicines following your discharge, you must take the hospital medical report to a public Primary care centre (Centro de salud) where a doctor will give you a prescription. This is because doctors in public hospitals will prescribe medicines on the appropriate medical report but do not issue official prescriptions.


There are no reimbursements as state-provided healthcare is free of charge.

If you have had to pay for the cost of your care, you should contact your national health insurance provider when you return home to claim a reimbursement.

Will the EU Stop Abuse of the EHIC System?

Possibly, but it could take some time. It should be noted that the launching of proceedings by the European Commission against the Spanish Government is only the first step in a three-stage infringement procedure. The Commission's request for information takes the form of a letter of formal notice, the first step in EU infringement procedures. Spain has two months to respond to the concerns expressed by the Commission. If Spain fails to furnish Brussels with a satisfactory response it will issue Spain with a “reasoned opinion,” and if the Commission feels that not enough is being done to remedy its concerns, it can refer Madrid to the European Court of Justice. However, such cases are rarely solved quickly, and can often run into a number of years. Even then, there is no guarantee that Spain will follow the stipulations of the court, whatever its judgment may be.

What Does This All Mean For Expats?

It must be stressed that the EHIC is not designed to entitle free medical treatment to a holder on a long-term basis, so if you have become a long-term or permanent resident of another EU Member State it should absolutely not be relied upon should your health fail or you have an accident. Therefore, you should have adequate private health insurance cover in place to meet your needs, or ensure that you are paying the appropriate contributions to the public health system in your adopted country. At the least, this will give you peace of mind that you won’t be turned away if you need medical attention, or face a huge bill that will eat into that carefully nurtured retirement nest-egg.

Unfortunately, there is no one-size-fits-all solution to this problem, and much of the leg work will have to be done by an individual who is contemplating a prolonged stay abroad, or planning to live permanently in another country. As Robin Pegg, Chief Executive Officer of specialist international health insurance brokers Medibroker observes: “For the individual faced with the need to access emergency care today, the news that the EU is taking action against Spain brings little comfort. Whilst the position of the short term holidaymaker should be relatively straightforward, those on longer breaks and those who have moved abroad may well find themselves in a medical insurance black hole, unless they have taken professional advice.”

Pegg adds: “For the moment, while details of the Spanish issue continue to emerge, we feel the best advice is to talk to your broker to find out exactly what is, and is not, covered. Advice is free, and it may well prevent problems down the line.”

Expats and other frequent travellers, even if they are travelling mainly within the EU, have special needs for health-care and related insurance services, and a substantial industry has sprung up to satisfy them. Our partner website, Investors Offshore, contains much helpful information on obtaining health-care abroad, including The InvestorsOffshore Guide To Health And Life For Expats, an extensive study of the health-care and insurance needs of expatriates and the services that exist to assist them.

Tags: business | Europe | Offshore | expatriates | retirement | Insurance | investment | Spain | Switzerland | Iceland | Liechtenstein | Norway | United Kingdom | law | offshore | European Commission | services | public health | private healthcare | insurance | tax | social security |


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