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Recortes de Prensa

Expat guide to Spain: health care

The Telegraphe, 24 | 03 | 2010 - ¿?

Don’t feel the pain in Spain. In the second of a series of expat guides, Peter Pallot writes on the best approach to Spanish health care for British expatriates

Think ahead. The government, social researchers, charities and insurance advisers all agree that forward thinking is essential for those settling in Spain. Good health can collapse at any stage. It will throw the individual into the state or private health system. It can be testing.

The deep cultural differences between north and south Europe should not be underestimated. Because of the strong emphasis on family ties in Spain, elderly people suffering from diseases such as Alzheimer’s rely on relatives. Nursing homes and care homes are almost unknown – and Spanish citizens get priority.

There is no equivalent of the outreach services provided in the UK. Relatives may be called on to supply meals and bed linen for in-patients. The language barrier can delay recovery and prompt misdiagnosis. But standards in Spanish clinics and hospitals are arguably better than the NHS.

Such considerations may seem of no consequence to healthy middle-aged people retiring to the costas. But the thousands of Britons who have recently returned to the UK for health reasons suggest otherwise.

When you get there: state or private care?

People going to Spain are advised to fix up private medical cover in advance. Alternatively, you should register with the local authority within a few weeks of arrival. (This potentially exposes you to tax.) You get a tarjeta sanitaria (medical card) and you have the same healthcare rights as a Spaniard in the state system.

Private healthcare options

International market leader Bupa bought the large Spanish insurer and care provider Sanitas in 1989. Bupa’s Sanitas Health Plan Complete is tailored to cover expats who flip between Spain and their home state, although policyholders can designate whichever European country they choose. The UK is a popular option.

Insurers IMG, Lamp, ALC and Expatriate Healthcare offer schemes similar to Bupa’s Sanitas plan. But major providers with Europe-wide schemes, such as Axa-PPP, are rated to be as competitive, and may offer additional benefits.

These plans from UK-based insurers are designed to control costs by limiting geographic cover. They are not full international insurance. But they are more expensive than plans specific to Spain.

However, UK plans will often allow for repatriation – the policyholder in Spain who wants a knee replacement done privately in Britain will then be covered for return transport.

Spanish insurance plans

A greater proportion of Spain’s population has private health cover (18 per cent) than in Britain (11 per cent). Premiums are significantly lower, but choice of hospital is often restricted.

Iberian plans are aimed at the local market. Health insurance brokers claim that the small print in Spanish policies may be ambiguous or misleading after translation.

Buy in UK for protection

People due to settle in Spain may benefit by buying insurance in advance from a company regulated by the Financial Services Authority. It is seen as consumer friendly. That matters if a dispute arises.

Is your broker just an agent?

Some expatriates buy cover soon after they arrive in Spain. Some renew cover in their adopted country when the premium year ends. If you use a broker, you should ask how many companies they represent. Do they have the software to trawl the market for the best deal? Or are they just an agent for a single insurer?

Spain was behind the rest of Europe in implementing the EU insurance mediation directive. This requires “brokers” to sell products from competing insurers. The move followed claims that single-company agents were styling themselves as brokers. The directive took effect in January 2005. Spain implemented it in July 2007.


You should ask brokers what commission they are taking. If excessive, request a portion. You can compare the offered plan with an online sale. But no two policies are the same, making comparison tricky.

State health care

Expats in Spain say state healthcare is as good as the NHS. Research supports this. Spain spends a greater proportion of GDP on health than Britain. It has more practising doctors: 3.6 per 1,000 population compared with 2.5 per 1,000 population in UK, according to the King’s Fund.
What the experts say

A major analysis in December 2006 into the British craze for buying property abroad emphasised the need to research healthcare before leaving the UK. Four years on, the Institute of Public Policy Research (IPPR) followed up its Brits Abroad report, further highlighting the dangers of assuming that good health on retirement will necessarily continue.

The original report said that those moving abroad “spared not a thought” about growing old in a country where local doctors speaking foreign languages could not understand them, or where service provision was unlike that of the UK.

Laura Chappell, senior research fellow at the IPPR, now says: “A lot of people have not researched enough the differences in health provision within Europe. In our focus groups, people said health insurance was something they only thought about when they’d been living in their new country for quite some time. It’s not in people’s minds when they are emigrating – as it should be.”

Language barrier

The government-backed Brits Abroad report stressed the importance of learning the local language. Study group interviewees who lacked language fluency compounded their medical problems. The risk of misdiagnosis increased. Patients could have difficulty making known what they wanted. Particularly in Spain and Portugal, charities and non-governmental organisations reported “significantly growing numbers” of Britons seeking repatriation because of failing health.

Help on the ground

Age Concern Espana, which supports some 15,000 Britons a year, says falling interest rates and the poor sterling-euro exchange rates have worsened an already dire situation.

“The income of many expatriates is at a historic low just when they may most need funds,” says Stefano Gelmini, senior media officer for Age Concern England.

Since last year, the charity has been working with the Foreign and Commonwealth Office and another charity, Age UK, in a project, One Stop Service, which aims to co-ordinate help for Britons with health or money problems.

Know your E numbers

Those eligible for state health care include

* retired EU foreigners who follow correct procedures;

* the employed and the registered self-employed.

Not eligible are:

* non-working expatriates below retirement age, unless they register;

* pensioners who have not completed the formalities.

Spain is cracking down on the large numbers of expatriates from northern Europe “freeloading” on its state health care. Certain E (for EU) documents give access to the system.

1) EHIC In January 2006, form E111 evolved into the European Health Insurance Card (EHIC). It is primarily aimed at holidaymakers or those on short stays within the EEA and Switzerland. The EHIC opens the door to “all necessary treatment,” but interpretations of that phrase vary widely. The Department of Health says: “You are advised to take out comprehensive private insurance for visits to all countries, regardless of whether you are covered by the EHIC.”

2) E121 State pensioners should get an E121 from the Department for Work and Pensions before departing the UK to live in Europe. It “de-lists” them from the UK social security system. Within three months of arrival in Spain, they should report with their passport to a Foreigners’ Office (Oficina de Extrajaneros) or a police station. They will receive a certificate allowing them to register with the local sickness insurance office.

3) E106 Britons who have been employed, or registered self-employed, in Spain for two years may extend their eligibility of access to state healthcare through the E106, usually by two years at most.

4) E109 The E109 covers your family living in another member state. You must remain living in your home country, working and paying National Insurance.

Retire early and run a risk

Many non-working early retirees in Spain, and non-registered self-employed Britons, rely on the EHIC. This could be a costly error. The Foreign Office advises: “Those who settle in Spain after early retirement, ie before the normal UK pensionable age, should consult their local DSS office before travelling.”

If registered self-employed, you pay a levy and are entitled to the same benefits as a Spaniard. British men over 65 and women over 60 are also “in” if they have completed the E121 formalities.

The problem area is the non-working, early-retired expatriate. As long as you are employed, your employer should be contributing to the social security pool, and you are entitled to full treatment.

Valencia was the last province with a strong expatriate community to act against individuals accessing healthcare without paying. Last year, it announced that non-working expats under retirement age would pay a €90 monthly levy.

Where do EHIC limits lie?

What can you expect in terms of care with an EHIC? Medicine is a liberal profession. Some doctors will take a charitable view of what constitutes “emergency” medicine available under the EHIC. Others won’t, and may be under pressure to economise.

Spain’s health system is province based. Attitudes, if not regulations, vary.

Returning home

Strict curbs on access to the NHS apply to returnees. Britons who spend less than six months a year in the UK, but within Europe, are denied non-emergency access to the NHS.

This could be a blow for expats in Spain who planned to return home for elective surgery, such as hip replacement, cataract removal, hernia repair or non-urgent cardiac surgery.

But expat retirees who have not completed formalities cannot expect non-emergency care in Spain, either.

The British embassy in Madrid summed up the situation: “UK nationals living in Spain, but not officially resident, are not automatically entitled to health care in Spain at UK expense.”

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