Do you need to take out voluntary 'top-up' health insurance in France, and if so, what do you need, and how do you go about getting it?

France may well be the benchmark health system for all others, but it is not one that is free at the point of access.

Unlike the universal nature of the health system in the United Kingdom, in France a multi-layered insurance based system exists, in which the statutory system providing basic cover is supplemented by a system of secondary private insurance.

What is Complementary Health Cover?

These secondary, or complementary, insurance policies are called l'assurance complémentaire santé.

In English the policies are variously described as 'complementary' health insurance, 'voluntary' health insurance and, more colloquially, as 'top-up' health insurance.

The secondary market exists because, for most individuals, and for most types of health care in France, the statutory system only reimburses a percentage of your costs, normally around 70% for routine treatment and 80% for hospital treatment. Alsace-Moselle has particular arrangements, with levels of reimbursement that are higher.

This means of course that you either need to pay the balance out of your pocket, or take out an insurance policy to cover them.

This rule applies whether or not your health cover is provided through an S1 health certificate of entitlement, as the S1 only grants entitlement to the same level of reimbursement as French nationals.

Accordingly, as a retired person, or an early retiree on an S1, you will need to consider taking out l'assurance complémentaire santé.

Similarly, if you run a business in France you will need to consider taking out complementary cover. Salaried workers are frequently covered by collective policies, but not in all cases.

Who Provides the Insurance Cover?

These complementary insurance policies are provided by insurers, who are collectively known as organismes de complémentaire de santé (OC).

They may be either non-profit making 'mutuelles' or private insurance companies, although do not assume from the nomenclature that the former are necessarily less expensive.

There are several hundred such insurers, but many are reserved for specific professional groups or collective company insurance schemes. Some also serve only a specific geographic area, whether a department or region.

In the case of the private insurers the major players for individual insurance are Covéa, Axa, Groupama, Swiss Life, Macif and Alliancz (and their subsidiaries), whilst the major mutuelles are MGEN, La Mutuelle Générale, Harmonie Mutualite and MNH.

The mutelles control around 56% of the market, with the private insurers picking up around 27%.

The rest of the market is covered by a number of newer entrants, notably provident funds (institutions de prévoyance) and some banks - Credit Mutuel, Credit Agricole (Pacifica) Banque Postale and BNP Paribas.

What do they Cover?

Even though the statutory system only covers a proportion of your costs that does not necessarily mean that the complementary insurers cover the balance of your costs. It will depend on the type of contract you hold.

Rarely do all complementary health contracts cover all additional costs, and those that do are so expensive as to normally be uneconomic.

It is impossible within the framework of this article to describe all of the different charges within the health system and their levels of reimbursement.

However, broadly speaking, it can be summarised as follows:

• Over and above the basic 70% reimbursement level, the fees charged by many consultants is higher than the statutory rates for treatment. These additional charges are called dépassements d'honoraires.
  
• Most medicines are not fully reimbursable, some as low as 35%.
• Hospital charges (which can obviously be very substantial) are normally only covered at the rate of 80%.
  
• There are also certain hospital services and facilities not covered by your basic insurance, eg private room, television.
  
• Finally, the levels of reimbursement for dental treatment and spectacles is also well below the actual charges.
  

All of which would indicate that you need to take out complementary health cover. Perhaps, but before you jump to that conclusion three caveats need to be added.

Firstly, if you have a prescribed serious medical illness, the health system will cover all of your basic costs at the rate of 100%, provided the charges are at the official rate. So there is a certain level of peace of mind about your costs if you do become seriously ill. You will still need to pay extra, or have insurance, for a private room in a hospital, or possibly a television in your room, as well as certain other minor non-reimbursable charges. Neither, as we stated above, will the basic insurance cover any consultant charges over and above the official rate, which have now become very common.

Secondly, unless you have the right policy, those charges in excess of the official rate will not be reimbursed by your complementary cover. This is because the complementary health policies vary in the extent of their cover. At the bottom end a basic policy will cover your charges not met by the statutory system, provided these charges are at the official rate; at the top end there are policies that will cover all extra charges, and additional services and facilities you may require, eg private room.

Thirdly, if you are on a low income you can become entitled to receive 100% reimbursement of your costs, through the CMU Protection Complémentaire (CMU–C). Consultants treating CMUC patients are required to charge only the basic rate, although there is not right, for instance,to a private hospital room funded by the CMUC.

So in summary:

• In the event that you become seriously ill the statutory system will cover your basic costs;
  
• That even should you take out a complementary insurance policy it does not necessarily mean that all your costs are covered;
• And that those on a low income are fully protected.

Accordingly, in deciding whether to take out complementary health cover you need to weigh a number of different factors, which we shall consider next month, when we review some of the different policies on the market.