People who had difficulty getting reimbursed by the HSE for their surgery in another EU country under the Cross Border Directive (or under the Northern Ireland Planned Healthcare scheme) brought their grievances to the Ombudsman, Ger Deering, over the past few years.

He is there to examine complaints from people who feel they have been unfairly treated by a public service provider in Ireland.

Generally the above schemes work well, but occasionally not. So what kinds of problems did people have in getting their money back from the HSE – problems that led to the Ombudsman’s team initiating an investigation?

Many of the complaints were from people on State pensions, or those on public hospital waiting lists while in pain; waiting for hip replacements or cataract operations, for example.

“Many had borrowed significant amounts of money from family, friends or financial institutions to pay for their treatment (abroad) with the expectation that they would be able to pay them back when reimbursed by the State,” says the Ombudsman in his report In Sickness and in Debt.

“When a refund was subsequently refused, these patients effectively exchanged the anxiety and worry associated with their illness for a new stress of dealing with a debt incurred while accessing a treatment which they were entitled to receive, but could not access, within the State.”

So, what were their grievances?

First, many felt that the HSE was unsympathetic and inflexible when administrative or pathway errors occurred.

Second, many felt misled or that the information on the HSE website didn’t warn them clearly about eligibility or administrative issues they might encounter when seeking reimbursement – hence, contacting the Ombudsman.

What was turned down?

What kind of cases were turned down for reimbursement?

Those in receipt of UK pensions weren’t reimbursed.

“Due to the lack of information (about this complex area) these patients were unaware of the fact that being in receipt of a pension from another EU country would negatively affect their application,” Ger says.

His recommendation is that clearer explanation is needed on the HSE website and that its Cross Border Directive application form should be redesigned.

Case study: Margaret, a patient, had been asked to repay her refund of €11,500 after her application had been reviewed and the HSE noted that she was in receipt of a UK pension. She pointed out that there was no question on the application form which related to having a pension from another EU/EEA country. She was asked to repay this money after she applied for a further treatment the following year – by which time there was a question related to such income on the form.

Note: The UK has, of course, left the EU and EEA since this happened.

A GP hadn’t ‘signed’ a letter of referral to a hospital in Northern Ireland.

A GP hadn’t addressed a referral letter to a named individual within an ENT department. Even though the GP sent an amended letter addressing it to a specific consultant, the HSE refused to accept the amended letter. The applicant wasn’t reimbursed.

Initial consultation shouldn’t have taken place in Ireland.

Case study – Alice: An initial consultation took place while a Belgian consultant was in Ireland. The HSE ruled that the entirety of the healthcare must be accessed abroad. Alice didn’t get her money back.

Treatment should have taken place on a different day to the consultation.

Case study – Due to hospital rearrangements outside Agnes’s control, an outpatient consultation and treatment had taken place on the same day in a hospital in Lithuania. The HSE declined her application for a refund.

Consultation by telephone disallowed.

Case study – Paulina was refused a refund because she had her initial consultation related to chronic back pain with the surgeon in Poland via the telephone rather than when she arrived there.

Refund disallowed because documentation from the treating hospital wasn’t clear enough.

Case study – Paul’s mother: gross figures were shown on the receipt, rather than individual costs of treatment, travel/transfers, accommodation etc.


The Ombudsman has set out 21 recommendations to improve the HSE’s administration of these schemes. In the meantime, in light of the complaints he received, it would be advisable to:

  • Be sure to get prior notification from the HSE before you go. This is optional, but is advised if planning an overnight stay in a hospital abroad. This will show that you’ve followed the correct process and will show that you are eligible to claim reimbursement and how much you can claim back based on the diagnosis-related code your consultant uses. There is a specific application form for this. Responses take about 20 working days.
  • Make sure that the clinic abroad provides a breakdown of costs so that your invoice/receipt shows the true cost of the treatment alone. A total figure that includes accommodations/travel/transfer costs won’t suffice. Issues like this can cause delays in being reimbursed.
  • Let your GP know that applications have been refused in the past because GP referral letters weren’t ‘signed’ or because they were addressed to a department in a hospital rather than to a named consultant in that department.
  • Keep evidence of all travel (eg plane tickets, toll receipts or petrol receipts) to prove that you travelled abroad.
  • If you have an issue with the HSE’s decision, appeal it immediately. There is only a 10-day timeframe to do this currently. The Ombudsman has recommended that this should be 21 days.
  • Do seek clarification from the HSE about qualification details on their website; particularly if you are in receipt of income from other EU/EEA countries. The Ombudsman mentioned ‘several instances of inaccurate, outdated and vague information’. Page 5 of the HSE CBD scheme now states: ‘You may need to apply for the CBD scheme in another country if you get your income from another EU or EEA country or are a dependent of someone who does’
  • HSE comment

    The HSE says it is committed to making the required changes in the delivery of these schemes as outlined in the Ombudsman’s report and to providing ongoing assurance that the changes are being implemented.

    In 2022, 4809 applications under these schemes were approved with a total of €30.9m reimbursed.

    HSE website confusion clarified

    How do you interpret this sentence on the HSE website? Does it imply that you must already be ‘in the system’ (ie on a public health waiting list for a long time) to avail of the CBD scheme?

    To apply for the CBD scheme in Ireland you must:

    “Qualify for the healthcare you want as a public patient in Ireland.”

    The HSE, when queried, clarified the above for Irish Country Living:

    “The only requirement is for the patient to have a referral either from a consultant he/she is attending in the public healthcare system in Ireland or from a GP/dentist. If a patient is on a public patient waiting list for an operation, that is also considered acceptable as it indicates the patient had a referral.”

    It also means that the healthcare must be healthcare the patient would be entitled to as a public patient in Ireland, the HSE says. For example, some healthcare is not funded under the CBD, such as assisted human reproduction.

    Statement from Healthcare Abroad – a company which organises surgeries in Spain

    “We didn’t recognise many of the cases referred to in the Ombudsman’s report,” the spokesperson says.

    “The vast majority of the case studies in that report, as far as we could see, involved patients travelling to Northern Ireland, where healthcare is much more expensive than it is in the EU countries where we operate; therefore, patients end up making very large co-payments involving many thousands of euro in the North. (The HSE only refunds what a similar operation costs in the Republic of Ireland). Some cases in the report did involve EU travel by patients who did their own paperwork, especially when travelling alone to Poland. One of the attractions of availing of the services of Healthcare Abroad is the fact that we do all the paperwork on behalf of patients.

    “Under the EU Cross Border Directive 2014, every EU citizen has a legal right to travel to any other EU country for healthcare, with the home country reimbursing most or all of the costs.

    “Patients do not have to be on a waiting list to use the EU Directive. In Ireland, all that is required is a referral letter from either a GP or a consultant in a public hospital.”

    (This company organises diagnostic tests at home after a GP refers the patient to a chosen consultant abroad. The results are sent to this consultant who then makes a decision about what treatment is needed.)

    The spokesperson also pointed out that some people who already have private health insurance are opting to go abroad under the CBD scheme rather than have the operation here and make the co-payments (pay the shortfall) that may be required by their policies.

    Companies like the above strive, they say, to negotiate deals with the participating hospitals abroad to charge the same for operations as the HSE pays in Ireland, thereby eliminating ‘co-payments’ (shortfall payments) as much as possible. The company is paid a commission by the hospital abroad.

    More information

    If you are unsure if you qualify for the CBD or NI Planned Healthcare Schemes, click here or contact the Cross Border Directive office in Kilkenny. The office is known as the National Contact Point in Ireland.

    HSE Cross Border Directive, National Contact Point,

    St. Canice’s Hospital Complex, Dublin Road, Kilkenny

    General enquiries: 056 778 4546 or 056 772 0551

    Or email

    Healthcare Abroad can be contacted via this link or by ringing 01 2678011. There are also other companies based in Ireland that provide this logistical service also.

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