Print Posted By Lost in France on 21 Sep 2006 in Living in France - Banking, Taxes and Finance

Sickness insurance - Beneficiaries and conditions for entitlement

The conditions governing the granting of benefits are as follows: you must have worked at least 60 hours as an employee in the calendar month preceding the administration of healthcare, or have worked at least 120 hours as an employee in the three calendar months preceding the administration of care.

The conditions governing the granting of cash benefits are as follows: you must have contributed from a salary equal to at least 1.015 times the hourly S.M.I.C. (guaranteed minimum wage) during the previous six calendar months, or have worked 200 hours as an employee or similar worker in the previous three calendar months (or the previous 90 days).

Benefits in kind:

Employees and members of their families (claimants) are covered. For the reimbursement of some services (dental or orthopaedic prostheses, for instance), you must first have the agreement of the primary health insurance body (C.P.A.M.) to which you contribute (there is one in every department).{loadposition contentad}

The documents to be produced to obtain the reimbursement of healthcare from the CPAM are the prescription and the healthcare form issued by the doctor.

People entitled to health insurance can obtain a 'Carte Vitale' (green microchip card which certifies that you are entitled to these rights for four years). The 'Carte Vitale' is increasingly replacing the healthcare form supplied by doctors, and results in much quicker refunds.

In the event of hospitalisation, the insured person pays a daily amount for each day spent in hospital (not paid for by social security bodies). This may be covered by your mutual insurance scheme.

Border workers are entitled to benefits in kind either in the country of residence or in the country of employment. But members of the employee's family must, except in emergencies, request authorisation from the competent institution (that of the country of employment) in order to obtain healthcare in the employee's country of employment (Article 20 of Regulation (EEC) No 1408/71).

Cash benefits:

Salaried employees (under certain minimum conditions - see above, 'conditions for granting benefits) and job-seekers receiving unemployment benefit (and up to one year after the expiry of this) are entitled to daily allowances equal in general to half the average gross daily pay received during the three months prior to stopping work, with a 3-day grace period). In most cases, because salaries are paid monthly, employers continue to pay all or part of the salary and obtain direct refunds from the competent body.

To receive daily benefits in the event of stopping work, you must produce a certificate from your employer stating the hours of work and the amount of salary paid.

To prevent stoppage of work for health reasons being regarded as a termination of the employment contract, the employee must:
- inform his/her employer by sending the doctor's prescription for sick leave or extending sick leave as soon as possible (48 hours maximum);
- justify absence from work by means of one or more prescriptions for sick leave or extending sick which must be sent within 48 hours to the relevant health insurance body (CPAM) or to the Medical Service when the medical reason for the sick leave is given;
- refrain from working during the period of sick leave;
- undergo, where appropriate, a medical checkup at the request of the employer;
- resume work on the scheduled date;
- undergo a medical checkup to ensure fitness for work imposed by the Labour Code in the case of sick leave exceeding a certain period. The checkup is conducted by the industrial doctor.

Temporary residence in another Member State of the European Economic Area (except in the case of business trips):

If you live in an EEA Member State and you are staying temporarily in another Member State, ensure that you have form E 111 or E 119 (whichever is appropriate). To obtain this form, contact your health insurance body before you leave.




Source: European Union
© European Communities, 1995-2006


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