Yolanda v. Regional Healthcare Department of the Generalitat Valenciana

STS 16-11-2009 Appeal No. 4426/2008
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The plaintiff sued the defendant, Regional Healthcare Department of the Generalitat Valenciana (RHD) for a refund of medical expenses following its denial of fertilization treatment.

The plaintiff was carrying a genetic illness multiple endocrine neoplasia type II (MEN II). She had surgery after being diagnosed with the disease. Subsequently, the plaintiff decided she wanted to start a family, but she was unable to become pregnant. She did four cycles of artificial insemination, but was still unable to become pregnant. Prior to beginning another assisted reproductive technique (IVF), she was diagnosed with a tumor and required a second surgery before starting IVF. After the surgery, the plaintiff was told she needed to take the IVF along with a preimplantation genetic diagnosis, however such treatment was not available through the public health system. Thus, the plaintiff turned to private medicine for her treatment.

The plaintiff requested a refund of her private medical expenses from RHD, who denied the claim. She then sued RHD for the refund and the Social Court number 1 of Alicante granted the plaintiff a sum of 11,416.25 Euros. RHD appealed and the judgment was revoked by the Social Chamber of the High Court of Justice of Valencia, holding that there should be no refund of expenses as this was not a case of a life-threatening emergency in which the public healthcare system could not be used.

The plaintiff then appealed the judgment on the grounds of a contradiction in rulings; a judgment issued by  the Social Chamber of the High Court of Justice of Castile and Leon had found that that a plaintiff in a similar situation (i.e., who had turned to private medicine for certain non-emergency treatments were unavailable in the public healthcare system) was entitled to a refund.

The Court held that no refund should be allowed. The Court noted another prior decision in which it had held that there were certain inherent limitations to the assistance of Social Security, required in order to “ensure both efficiency and equity in services provided, as well as the needed financial stability of the system.”  Thus, in accordance with the constitutional mandate on the right to health protection and the relevant Royal Decrees, no refund was due as there was no “life-threatening emergency” (interpreted to mean imminent danger of death or a loss of function of organs of great importance) where the Public Healthcare System was unavailable.

“The appeal must be dismissed in application of the doctrine previously recorded, as in the examined case there is not a “life-threatening emergency”, according to the broad sense interpreted by the Chamber in accordance with the constitutional mandate on the right to health protection, Article 43.1 of the Constitution, which refers not only to the danger of imminent death, but also to cases of loss of function of organs of great importance for the self-assurance of the person. Indeed, the right to refund of expenses incurred in the performance of a genetic diagnosis in private healthcare, so that, in view thereof, the Public Health conducted on the patient the assisted reproduction treatment, lacks of a life-threatening nature as it does not involve an imminent danger of death or a loss of function of organs of great importance for the self-assurance of the person, so the appealed judgment does not breach the provisions contained in Article 5 of Royal Decree 63/1995 (applicable for chronological reasons).” Page 7

“Aplicando la doctrina anteriormente consignada el recurso ha de ser rechazado, ya que en el supuesto examinado no concurre la "urgencia vital", entendida en el amplio sentido interpretado por la Sala en consonancia con el mandato constitucional sobre el derecho de protección a la salud , artículo 43.1 de la Constitución, que no se refiere únicamente al peligro de muerte inminente, sino también a los supuestos de pérdida de funcionalidad de órganos de suma importancia para el desenvolvimiento de la persona. En efecto, la cuestión controvertida, el derecho al reintegro de los gastos ocasionados por la realización de un diagnóstico genético en la sanidad privada, a fin de que, a la vista del mismo, la Sanidad Pública realizara a la beneficiaria el tratamiento de reproducción asistida, no reviste carácter de urgencia vital pues, ni supone peligro de muerte inminente, ni de pérdida de funcionalidad de órganos de suma importancia para el desenvolvimiento de la persona por lo que la sentencia recurrida no vulnera las previsiones contenidas en el artículo 5 del Real Decreto 63/1995 (aplicable por razones cronológicas).” Pagina 5.

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