JUDGMENT OF THE COURT
14 May 2019
(Regulation (EC) No 883/2004 – Article 24 – Pensioner residing outside the competent State – Benefits in kind in the place of residence – Reimbursement procedure)
In Case E-2/18,
REQUEST to the Court under Article 34 of the Agreement between the EFTA States on the Establishment of a Surveillance Authority and a Court of Justice by the Princely Court of Liechtenstein (Fürstliches Landgericht), in a case pending before it between
Concordia Schweizerische Kranken- und Unfallversicherung AG, Landesvertretung Liechtenstein
concerning the interpretation of Regulation (EC) No 883/2004 of the European Parliament and of the Council of 29 April 2004 on the coordination of social security systems,
Questions to the Court:
26 By a letter of 13 July 2018, registered at the Court on 17 July 2018, the Princely Court decided to stay the proceedings and refer the following questions to the Court:
- Does [the Basic Regulation] merely lay down a minimum framework which must be complied with in order to prevent distortions of competition or are the rules of that regulation mandatory in so far as they also affect and restrict benefit obligations to be performed worldwide under the insurance contract? Is [the Basic Regulation] applicable to social insurance systems which merely oblige workers to demonstrate adequate health insurance but allow them, by way of contractual autonomy, to choose between several different insurers governed by private law and only require proof that an appropriate insurance contract has been concluded?
2.(a) Is a policyholder required, on account of the validity of [the Basic Regulation], to submit invoices which are covered by the insurance contract concluded within the framework of the statutory health insurance scheme to the social insurance institution in his place of residence, with the result that the social insurance institution which is situated in the Member State responsible for payment of the pension can be made liable for payment only once the institution in his place of residence has refused to pay or can a policyholder none the less rely on his rights under the insurance contract?
(b) If, in accordance with point (a), it is not possible for the policyholder to rely on the insurance contract:
Is that also the case where the insurance contract is concluded within the framework of the statutory insurance requirement but the contractual insurance goes beyond the minimum required by law and has thus been concluded to some extent ‘voluntarily’?
- If policyholders are obliged, in accordance with Question 2, to submit invoices first to the institution in their State of residence:
(a) Does this also apply to an insured person who has already been provided benefits under the contractual relationship for several years or is reliance by the social insurance scheme on [the Basic Regulation] contrary to the principle of good faith?
(b) Is a social insurance scheme entitled, relying on [the Basic Regulation], to make claims for recovery to an insured person because in the past it has provided insurance cover in excess of the level specified in the regulation, that is to say, it has provided benefits which do not have to be paid under the rules of that regulation, or it is contrary to the principle of good faith to make claims for recovery?
(c) Does, in the light of [the Basic Regulation], the provision of benefits by the social insurance scheme, without invoices having been submitted through the social insurance institution in the place of residence, also entitle the policyholder to the future provision of benefits, without the need to submit invoices through the social insurance institution in the place of residence?
III Answers of the Court
Questions 1 and 2
29 By Questions 1 and 2, the referring court seeks, in essence, to clarify whether Article 24 of the Basic Regulation provides a mandatory procedure for the provision of benefits in kind to an insured person who receives a pension from one EEA State but resides in another EEA State, where the State of residence has refused benefits in kind to the pensioner on the basis that those benefits fall outside the scope of its social security system. The Court will assess these questions together
58 The answer to Questions 1 and 2 is therefore that when a pensioner is not entitled to benefits in kind in the EEA State of residence, due to the fact that the benefits fall outside the scope of its social security system, the pensioner is entitled, pursuant to Article 24(1) of the Basic Regulation, to receive the benefits in kind at the expense of the competent institution in the EEA State under whose legislation the pension is paid. The pensioner has a right to submit claims for reimbursement directly to the competent institution in the EEA State under whose legislation the pension is paid, in particular, but not only, if he has been refused reimbursement by the State of residence. In accordance with Article 22(1) of the Implementing Regulation and Article 76(4) of the Basic Regulation, if the competent institution does not provide the pensioner with information as to the procedure to be followed, that must not adversely affect the pensioner’s rights vis-à-vis the institution.
59 In light of the response given to Questions 1 and 2, there is no need to address Question 3.