Remember to check French doctors' Optam contract - or risk paying more
Mutelle top-ups do not necessarily reimburse patients for care from practitioners who have not signed a sector 1 Option de Pratique Tarifaire Maîtrisée
It can be a frightening experience navigating a new healthcare system, even if you are fluent in French
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Mutuelle cover can vary substantially for certain procedures, depending on whether or not a doctor has signed an agreement called an Optam (Option de Pratique Tarifaire Maîtrisée - Controlled pricing option).
Reader Anthony Lea, 85, from Pyrénées-Orientales, points this out after he was left to pay €739 for a forthcoming knee operation that will cost €1,556.
This is because his surgeon is sector 2 – able to charge dépassement amounts above the standard state rate – and has not signed an Optam contract, under which such doctors agree to charge only modest dépassements.
His top-up insurer, Swiss Life, told him that it is standard that such procedures are reimbursed less.
The ‘table of guarantees’ for his policy indicates 105% reimbursement for non-Optam hospital surgery, compared to 125% for surgery by an Optam surgeon.
Read more: When are doctor fees rising in France and will reimbursement be affected?
The figure of 105% in this case relates to 105% of the basic state tariff for the procedure.
This was listed in the patient’s devis quote as being €778.06 (105% x €778.06 = €816.96).
Thus, the patient is out of pocket by €1,556.12 - €816.96 = €739.16. We consulted the rules for so-called ‘responsible’ top-up policies (the vast majority), and they state that patients should be reimbursed at least 20% more for Optam procedures com- pared to non-Optam.
In this case, Swiss Life’s quote respected this.
Swiss Life told us “this rule has been the same for years and has not been toughened recently”.
The firm said clients should check their guarantees and contact their insurer if unsure on any points.
Mr Lea said he was unfamiliar with Optam and had not realised the implications of 105%, as being related to the state tariff, meaning in this case his top-up will only pay out €38.90 on top of the state refund of €778.06.
The retired Royal Navy engineer said it had caused him “an unexpected financial burden”.
“I have lived in France for 30 years and my French is reasonable so I should have noticed this but did not.
“I have lived under a false comprehension of how mutuelles operate.”
His “comprehension was turned upside down” when he saw the devis.
He added: “The last thing on your mind when you are in pain is asking if the doctor is ‘Optam’ or not.”
