Top-up insurance: Remboursement or direct payment?

Health Care & Carte Vitale
#1

Dear all
For several years we’ve been with the local Mutuelle Familiale de Normandie. It was small, and not very quick at answering questions, but with many local medical encounters we handed over the CV and mutuelle cards and as if by magic, we did not need to pay anything to the provider.

We’ve just changed to Credit Ag’s in-house insurer. Pacifica.

From the policy paperwork it looks as though they want: estimates in advance before approving treatment, and then us to pay the bill and obtain a detailed receipt to claim reimbursement.

Any clues as to how long both approval and remboursement are likely to take? One could mean a holdup for treatment and the other could hit our pension cashflow!

And what happens if, eg, the dentist or cardiologist decides during a consultation that some immediate procedure is needed?

Any suggestions?

TIA
Ken

#2

Might I suggest you double-check that this is what Pacifica are saying…

I can understand the quotes needing to be agreed beforehand.
That’s standard in my experience… although it’s all done between the Dentist/opticien/whatever and the Mutuelle…
I don’t have to get the quotes myself…
I merely wait to learn what’s been agreed or if I need to find a cheaper solution.

I thought the whole point of CV and Mutuelle is that one doesn’t have to pay up front… one pays whatever is left outstanding after CV and Mutuelle have paid their bits…

OH needed urgent dental treatment… Dentist took CV and Mutuelle card…
took a look at OH’s problem and mumbled about how this was going to be expensive…
In the event, OH paid nothing… and this was before the Free Dental and Eyes came into force.

Don’t panic… just go and talk things through with Pacifica.

#3

@fabien might have a sensible view on this… and it might be worth getting a quote from him too… changing to another provider is not a drama if you are unhappy with the potential level of service you will likely get.

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#4

This has happened to Brits in my commune… went for a checkup and ended up on the operating table.
no problem… the CV and Mutuelle work wonderfully and if it’s “lifethreatening” the treatment will be done… “just like that…”

#5

If it’s a cardiologist the chances are you will then be classified as ALD and won’t pay anything for that condition.

#6

Might this Thread be a useful reminder to all of us.

Don’t sign anything unless you fully understand what “is going on…”.

Details about how things work… how things are done… etc
this should be ironed out beforehand… not come as a possibly nasty surprise later…

and… yes… I confirm @fabien is highly recommended by OH and me too…

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#7

@Ken_Welsby I’m been musing on your query… and I’m rather wondering if you have misunderstood.

could the small print be saying that IF your Mutuelle is NOT asked to agree the Devis beforehand (!!)… in such a case, You will be liable for paying for “whatever” yourself and providing the necessary documentation (bill/receipt etc) to the Mutuelle, in order to claim a refund of their portion (whatever that might be…)

#8

and isn’t it usually the case that the mutuelle will want to agree costs before hand where the choice of hospital/surgeon for the intervention is not in the usual practice… ie you choose yourself to go to a facility which is markedly more expensive than would be otherwise justified/approved :thinking:
You can’t blame the insurers for wanting to protect their (and their subscribers at large) interests, after all.
I’ve had a number of interventions at CMU’s and having presented my CV and mutuelle certificate, the costs have been met without further question. The only time this did not happen seamlessly was in respect of ambulance transport from the Charente (where I live) to Bordeaux for preplanned open heart surgery where my cardiologist had to agree with CPAM that the intervention could not be performed more locally as the distance involved was beyond usual limits (>100km IIRC)

#9

isn’t this the difference between tiers payant policies and the rest? I’ve caught sight of a few comments on French forums where a mutuelle is not tiers payant and the mutual takes really long times to reimburse.

#10

We have a mutuelle put in place by @fabien with Swiss Life and we have never had a delay with payments from them.
You pays your money… you takes your choice. Good health care doesn’t come cheap.

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#11

Tiers payant is an agreement some professionals have with mutuelle so this is completely different. For example, most pharmacies have set up the “tiers payant” and therefore, when you have a mutuelle you usually don’t pay anything. Given that your mutuelle is properly setup on your ameli.fr online account and said mutuelle have the proper agreements to accept tiers payant with pharmacies (almost always the case though). Hope that helps? :wink:

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