Claiming expenses for private healthcare services

The High Court of Justice of Extremadura has ruled that the operations performed in private health centres by the plaintiff patients, who underwent hip replacement surgery, were neither urgent nor vital, and therefore the claim for reimbursement of medical expenses is rejected.

The patients, who underwent surgery in private centres, had waited for the intervention in the public health system for prolonged periods, one of them for 11 months, with the Ombudsman for users of the regional health system recognising the exceeding of the maximum periods of time for health care and the infringement of the right to response times. The other patient, suffering from severe pain, was referred to the public trauma service shortly after his private operation, with an additional wait of six months.

The patients sued for reimbursement of the costs in the social courts, but their claims were rejected by the social courts, which considered that the operations did not meet the vital urgency criterion to justify reimbursement.

On appeal, the (*)TSJ of Extremadura referred to the criteria for jurisdiction established by the Supreme Court, stating that:

• neither the Social Court nor the (*)TSJ assessed whether there was a case of abnormal functioning of the health administration, which would be a matter for the contentious-administrative jurisdiction;
• therefore, as the claim has been lodged in the social jurisdiction, the vital urgency is assessed, an aspect over which it has jurisdiction;
• The forensic medical reports indicate that the condition of ‘vital urgency’ that would justify recourse to private health care was not met.

Given that it was not a situation of vital urgency, the patients’ appeals were dismissed. The (*)TSJ of Extremadura, clarifies that the claimant voluntarily chose private healthcare, as he was summoned to the public trauma service shortly after his private operation.

If you have any doubts regarding this issue, please do not hesitate to contact us by telephone at Núria Martí García or by e-mail at nmg@btsasociados.com, we will be delighted to help you.

(*)TSJ – High Court of Justice