Hospitalisation costs: when the French social security limits reimbursement in case of personal choice

Imagine: you live in Thann, in the Haut-Rhin, and you need to undergo planned surgery. Because you have heard that Professor X, in Strasbourg, is the best, you decide to be hospitalised there. Your GP supports you in this choice. But on your return, a nasty surprise: the CPAM (Caisse primaire d'assurance maladie) only reimburses you on the basis of the tariff of the Mulhouse hospital, which is closer. You are left with an out-of-pocket expense of several hundred euros. Unfair? Yet this is what the Court of Cassation validated in a judgment of 5 January 1973, still relevant today.

But what exactly does this change? Every year, thousands of insured persons are confronted with this little-known rule. The choice of healthcare establishment is not completely free: if you opt for a more expensive and more distant hospital than the nearest reference establishment, the French social security limits its contribution. The decision analysed here sets out the scope of this limitation, and it concerns both patients and the doctors who advise them.

In short, this judgment concerns you if you are to be hospitalised, but also if you own property that you rent to healthcare professionals, or if you manage a condominium where home care is organised. Because the rule goes beyond simple reimbursement: it touches on the patient's freedom of choice and the distribution of costs between the insured person and the community. Let's decipher this reference decision together.

The facts: a story that happens every day

The case pits the primary social security fund of Maubeuge against the Y family. Mr Y is domiciled in Maubeuge, in the Nord. His wife, Mrs Y, is hospitalised at the university hospital centre of Lille for planned care (non-emergency). The problem? There is a suitable healthcare establishment much closer to Maubeuge, and its responsibility tariff (the basic tariff used for reimbursement) is lower than that of Lille.

The fund therefore refuses to cover the full cost of Mrs Y's stay on the basis of the Lille tariff. It offers a reimbursement limited to the tariff of the nearest establishment. Mr Y contests: he argues that the choice of Lille was made on the advice of his GP, and that it is not a matter of pure personal convenience. He takes the matter to court.

The proceedings follow their course: first the first instance commission, then the court of appeal, and finally the Court of Cassation. The twist? The High Court confirms the fund's position, but specifies that the medical nature of the choice (was it really necessary to go to Lille?) must be decided by a technical expert, not by the judge. In other words, if the GP considers that the nearest establishment is not suitable, the tariff of the chosen establishment may be applied, but only if this is proved.

undefined, I have come across cases where insured persons, despite being well advised, were faced with this refusal. The key is often in the prior information: the fund must inform you of the reimbursement conditions before the care is covered. Here, the Court of Cassation reminds that the insured person must be informed at the time of admission, and that he has one month to contest and request a medical expert opinion.

The reasoning of the court — dissected

The Court of Cassation relies on Article 1 bis of Decree No. 62-147 of 5 February 1962, supplemented by Decree No. 64-881 of 21 August 1964. In simple terms, this provision provides that if an insured person chooses, for personal reasons, a healthcare establishment whose responsibility tariff is higher than that of the nearest public or private establishment to his residence, the fund only reimburses on the basis of the tariff of that nearest establishment.

Note, however, that this choice includes not only the personal decision of the insured person, but also that made on the advice of his GP, or even directly by the doctor on behalf of the patient. What few people know is that the rule applies even if the doctor recommends a distant establishment, unless that establishment is the only one able to provide the appropriate care.

The judges make a subtle distinction: if the dispute concerns whether the appropriate care could have been provided in the nearest establishment, it is a medical difficulty. It must then be resolved by a technical expert, not by the court. Conversely, if the discussion concerns the personal choice (no emergency, convenience), the judge can decide.

The Court of Cassation therefore has a dual effect: on the one hand, it validates the principle of limiting reimbursement; on the other hand, it opens the way for a medical challenge, but with strict time constraints (one month from the contested decision). In this case, the court of appeal had not ordered an expert opinion, which justified the cassation. But on the merits, the reasoning confirms the previous case law: no total freedom of choice at the expense of the community.

What this changes for you — concretely

For patients: if you are considering planned hospitalisation, find out about the nearest establishment to your home (for example, the Mulhouse hospital if you live in Rixheim). Ask your doctor if this establishment can treat you. If he refers you elsewhere, make sure you obtain a medical certificate justifying that the necessary care cannot be provided locally. Without this, you risk a significant out-of-pocket expense: the difference between the tariff of the chosen establishment and that of the reference establishment.

For landlord owners: if you rent a property to a doctor or a clinic, be aware that reimbursement for care can impact the clientele. A clinic located in an area where the public reference establishment is cheaper could see its patients face refusals of coverage. This may affect the attractiveness of your property.

For co-owners: in a residence where home care is organised, the patient's choice to be hospitalised rather than treated on site may also be affected. For example, if a physiotherapist provides home care but the patient prefers to go to a distant rehabilitation centre, the same principle applies.

Numerical example: if the tariff of the Mulhouse hospital is €1,500 per day, and that of the Strasbourg hospital is €2,000, for a 5-day stay, the fund will only reimburse €7,500 (Mulhouse basis) instead of €10,000. You will have to pay €2,500 out of pocket, unless your mutual insurance company takes over (check your contract).

Four tips to avoid this type of dispute

• Check the reference establishment before hospitalisation: contact your CPAM (Caisse primaire d'assurance maladie) to find out the tariff of the nearest establishment to your home. A simple phone call can save you an unpleasant surprise.
• Obtain a written medical opinion justifying the distance: if your doctor refers you to a more distant establishment, ask him for a reasoned letter, dated and signed, explaining why the local hospital is not suitable. This document will be valuable in case of a dispute.
• Respect the one-month deadline to contest: if the fund notifies you of a limitation on reimbursement, you have one month to request a medical expert opinion. Do not delay: after this deadline, you lose any recourse.
• Keep all documents: keep the fund's letters, medical prescriptions, hospital reports. In case of a dispute, these documents are essential to prove that the choice was not one of pure convenience.

Further reading: related case law and developments

This 1973 decision is part of a consistent line. We can cite a Court of Cassation judgment of 14 February 1974 (No. 72-14.127) which specifies that the rule applies even if the insured person was referred by his GP, thus confirming the 1973 position. More recently, a judgment of 10 October 2019 (No. 18-20.153) recalled that a medical expert opinion is mandatory as soon as the patient contests the adequacy of care in the reference establishment.

The trend in the courts is therefore to maintain a strict interpretation: the patient's free choice is not absolute when it results in an additional cost to the community. What this means for the future: with the rise of extra fees and private clinics, the funds will be increasingly vigilant. Insured persons will need to be better informed, and healthcare professionals will need to justify their referrals.

Frequently asked questions

What is the responsibility tariff?
It is the basic tariff set by the French social security for a procedure or a stay. Reimbursement is calculated on this tariff, even if the establishment charges more.

Can I choose the hospital of my choice without financial penalty?
Yes, but only in the case of an emergency or if the nearest establishment cannot treat you. Otherwise, you will have to pay the difference.

What should I do if the fund refuses to cover the full cost?
Request a medical expert opinion within one month of the decision. This expert opinion will determine whether the nearest establishment could have treated you.

Can my mutual insurance cover the surplus?
Some mutual insurance companies provide a "fee excess" or "daily allowance" guarantee. Check your contract, but note that mutual insurance companies are not required to reimburse this type of difference.

Does this rule also apply to outpatient consultations?
No, it concerns only hospitalisation costs. Outpatient consultations are subject to other rules.

Are you in a similar situation? A first 30-minute consultation with Maître Zakine (€45) can save you months of proceedings — and often much more. Make an appointment →