Falling ill in a foreign land may provide some surprises when it comes to treatment cover. Kathryn McCarthy looks at how UK expats fare abroad.

Opening borders in the EU and the globalisation of business means more people are working and living abroad. The availability of free healthcare is often taken for granted in the UK, but expatriates face a different story overseas.

International private medical insurance (PMI) is an essential consideration when choosing to live or work abroad. Standards in medicine and facilities vary from country to country, and such uncertainty can be daunting for the unwary expat.

Without PMI, falling ill in a foreign land can be a costly experience, as the patient is liable for the entire healthcare bill. EU citizens within EU borders, however, are better protected, as they are entitled to emergency care for free and some other types of care under reciprocal arrangements.

PMI aims to provide cover for most healthcare eventualities for expats, from local emergency care and repatriation, right through to elective medical treatment and dentistry.

Things to think about
As policies can vary between insurers, there are several key issues to consider when purchasing expatriate healthcare coverage. These are: service support levels for processing claims, portability of the insurance to different postings or for holidays, tailoring to fit specific needs, coverage for chronic conditions, local licensing of the provider in the foreign country, repatriation and 24-hour assistance. Some insurers have restrictive provider listings that limit treatment to certain medical facilities, which may be adequate in some cases but may not suit each insured.

John Bibby, marketing director of the Primary Group, which owns Goodhealth International Healthcare, says: "From our experience as an international healthcare provider over the past ten years, it's clear that living and working abroad is a significant change in lifestyle, particularly for those used to relying on the state healthcare provision.

"Even those used to private health insurance policies will find, dependant upon their choice of expatriate healthcare provider, that service levels will be different."

In some countries like the Czech Republic and parts of the Middle East, medical insurance is compulsory for expats. France, on the other hand, has a highly regarded national healthcare system and a state insurance scheme, Couverture Maladie Universelle (CMU). CMU is similar to national insurance in the UK, and it is compulsory for all residents to pay contributions.

CMU was introduced in France in January 2000 and applies to all residents, including foreigners. There has been speculation that the new system effectively outlaws private medical insurance for expatriates, but this is not so. The rules for CMU are complicated, but largely speaking, UK expatriate "posted" workers and their families holding an E101 form can reside in France for up to five years without contributing to the state scheme. Provided they also have an E106, they are entitled to register to receive healthcare in France while temporarily resident.

Non-exempt foreign nationals become resident after three to six months, at which point they must contribute to CMU. However, "top-up" PMI can be purchased to cover the 20% to 30% of costs not covered by the state.

There are a number of exemptions to the CMU scheme, but there is little consensus among international PMI providers on what effect CMU has on selling private medical insurance in France.

Putting CMU in context
Graham Trueman, international marketing manager at PPP Healthcare, says: "It's important to understand the context of CMU. The popular view in France is that CMU is targeted towards the less well off to ensure that they benefit appropriately from the French healthcare system. It does not appear to have been the intention of the government to deliberately target expatriates. We are continuing to investigate the implementation of this legislation and, once we've satisfactorily clarified the situation, we will know how best to be of service to our customers in France."

France has a large UK expatriate community, many of whom hold residency status. Their PMI insurance needs have changed under the new system and some healthcare providers advise caution when buying private cover.

Bibby confirms this: "The current situation is that, in order to become a French resident, you are obliged by law to enrol within the French state healthcare system. This essentially makes most expatriate healthcare policies redundant within France. Furthermore, in order to ensure enrolment within the state provision, private health insurance policies that replace the benefits provided under the state provision have been outlawed by the French authorities.

"It is, however, possible and advisable to purchase a top-up insurance policy, which compliments the state provision. Various legislation exists governing the sale of all insurance products within France and it's important to ensure that the policy is compliant."

PMI not substitute
Bupa International emphasises that international medical insurance products are not a substitute for CMU membership, and foreign nationals who do not qualify for exemption have a tax obligation to contribute to the state scheme. Comprehensive PMI may be purchased by the self-employed and employed expat population in France. However, some people in this category will still be obliged to contribute to CMU.

"We've been following the developments regarding the changes in legislation relating to the French state healthcare system and, in particular, universal health coverage in France," says Bill Ward, managing director of BUPA International. "We're currently considering various options which will be beneficial to our members in France."

The peculiarities in the French system illustrate to some extent the difficulties faced by expatriates relying on their host country's national healthcare regime. What is clear is that no two countries are alike and, as people migrate in ever greater numbers to live and work abroad, international PMI providers have a growing market for their products, advice and local expertise.

Cover for chronic conditions
Not all international PMI policies provide cover for chronic conditions. A chronic condition is defined as a medical condition that cannot be cured by treatment. There are two types of chronic condition: degenerative, such as cancer, and stable, such as arthritis. Some corporate schemes include the cover, and some policies offer it as an optional benefit.

BUPA International: The company is in the process of creating a product that may include some cover for chronic conditions. No further information is available on this, as the product is still in development.

PPP: Chris Knott, director of international business, PPP Healthcare, says: "Chronic conditions have become a critical requirement for many multi-national companies. PPP healthcare has already developed international corporate schemes covering chronic conditions and will continue to evolve to fit the needs of the international market place."

Goodhealth: Cover for chronic conditions is optional, limited to a maximum of $42,500 (£29,900) per annum for five years from diagnosis. Cover is restricted to new medical conditions occurring after the purchase date.

Exeter Friendly Society: Cover extended for degenerative chronic care, as best practice. Stable chronic conditions may not be covered if it requires ongoing secondary care.

Medicare: Cover available for chronic conditions with no distinction between stable and degenerative.

Interglobal: Cover for chronic conditions available under group schemes.

Europ Assistance: Cover provided under group schemes for certain chronic conditions, underwritten on a case-by-case basis.