Coverage of diseases by mutuality


From consultation to reimbursement

To take advantage of the best coverage for medical expenses caused by a disease, it is essential to coordinated care trajectoryinitiated by the statement of an attending physician.

Consult the treating physician

Consultation of the doctor is the first step in the coordinated care process. He is responsible for coordinating care and medical follow-up and is often best placed to prescribe the treatment of a disease with the prescription of drugs.

The rates of reimbursement of medicines are variable (100%, 65%, 30% or 15%), depending on their medical importance, and require mutual health insurance to compensate for the remaining costs.

Consult a specialist or hospital doctor

At the request of the attending physician, it may be necessary to consultant or hospital if the disease diagnosed requires further expertise. The specialist can then request further examination, offer treatment (admission, medication, equipment, etc.) and monitor the patient if necessary.

Reimbursement by the health insurance

Only people affected by one of the 30 chronic, serious or debilitating diseases listed on the list of long-term diseases (ALD) can benefit from 100% coverage by theHealth insurance†

For other patients, it is generally necessary to repay the remainder out of your own pocket after reimbursement of medical costs by the health insurance. So it is the case of user costsbut also exceeding fees, hospital packages and medical prescriptions that are not reimbursed by social security.

Coverage through mutuality

To take advantage of a full support, or partially, of the proof of mitigation and other medical expenses still to be paid, the patient can return to his health insurance fund. Depending on the degree of coverage of the various medical matters (optics, dentistry, hospitalization and daily care), the coverage will be higher or lower.

For basic medical services such as the purchase of medicines or a consultation as part of the coordinated care process, 100% coverage, ie the basic level, will be sufficient. However, it will not allow any excess fees or certain necessary comfort costs to be refunded in the event of:hospitalization†

As the Additional health of the patient is connected to the health insurance (via the NOEMIE system), healthcare costs are automatically forwarded and reimbursement is accelerated. Otherwise, the patient must send the reimbursement overview from Social Security to his health insurance fund.

The main families of diseases

Understanding how a disease works sometimes makes it possible to better approach treatment, medical support, or simply certain fears. It is also a way of ensuring that you benefit from good mutual health insurance coverage.

Heart and vascular disease

The heart and vascular disease are diseases that affect the heart and circulatory system. With more than 16 million deaths a year, they are the 1time cause of death in humans worldwide according to the World Health Organization (WHO). Among the main cardiovascular diseases we find aneurysm, myocardial infarction, cardiac arrest or arterial hypertension.

Neurodegenerative Diseases

Neurodegenerative diseases are chronic disabling diseases with a slow and discrete evolution. The most well-known to the general public are Alzheimer’s disease (progressive and irreversible loss of mental functions and in particular of memory), Parkinson’s disease (slowing of movements, tremors, rigidity, cognitive impairment) or Huntington’s disease (loss of motor and cognitive skills, psychiatric disorders).

The different forms of cancer

A cancer (or malignant tumor – also called “neoplasm” or “neoplasia” in the medical world) is a disease characterized by abnormally large cell proliferation, which threatens the survival of normal body tissue.

Because there are as many sources of cancer as there are tissues in the body, cancers are classified according to the organs affected. For example, we find breast cancer, colon cancer, lung cancertesticular cancer, bone marrow cancer (or multiple myeloma), or leukemia (blood cancer).

In the case of cancer that has been diagnosed by a specialist, the associated care is 100% reimbursed by the health insurance, but it only concerns treatments that are directly related to the disease. For uncovered costs, it is necessary to take out additional health insurance, which will be able to reimburse the “outstanding costs”.

infectious diseases

Caused by the transmission of a microorganism or an infectious agent (virus, bacteria, parasite, fungus, etc.), infectious diseases are the 2e leading cause of death in the world, with more than 10 million victims per year.

Among the infectious diseases that cause the most damage, we note the presence of: respiratory diseases, diarrheal diseases, tuberculosis, malaria or even measles. Sexually transmitted diseases or infections (STDs or STIs), especially AIDS, also have important implications for global health. Other rarer diseases, such as lead poisoning (lead poisoning) or botulism (paralytic disease).

Respiratory Disorders

Smoking (active, but also passive) and air pollution are scourges to human health. They cause or accentuate respiratory diseases, which can lead to, for example: COPD (chronic obstructive pulmonary disease), ie a permanent and progressive obstruction of the airways.

The vaccination

To combat or protect against a contagious disease, vaccination is generally essential. This process consists of the introduction of an external agent (the vaccine) to provoke a positive immune response against the disease.

The cost of a vaccine (mandatory as recommended) is reimbursed up to 65% by health insurance, on medical prescription, while the injection is 70% reimbursed when performed by a doctor (60% by a nurse). The rest of the costs can be covered in whole or in part by the health insurance company according to the guarantees in the contract.

Mental illness

Mental illnesses (also called mental disorders or mental disorders) correspond to all conditions and disorders that lead to difficulties in a person’s life, suffering and behavioral disorders. These conditions have multiple causes and can affect all populations, regardless of age or gender. They can also be chronic or permanent.

One of the most widely publicized mental disorders is: Obsessive Compulsive Disorder (TOC). It is characterized by repeated intrusive thoughts called obsessions, which only repetitive and ritualized behaviors called compulsions can relieve. Another condition popularized with the general public by Molière’s “The Imaginary Invalid”: hypochondriasis (or hypochondriac disorder), that is, an excessive fear and concern about the health and proper functioning of a person’s body

Here is a non-exhaustive list of other examples of mental disorders:

  • the Depression ;
  • addictions;
  • alcohol or drug use disorders;
  • anxiety;
  • phobias;
  • eating disorders;
  • schizophrenic, bipolar or “borderline” disorders.

the allergies

Some diseases are caused by: allergy (ie, a pathological exaggeration of the immune response) to an element (called an allergen) in the body. The main families are respiratory, skin, food, drug and poison allergies. The most common and well-known reactions are eczema, hives, allergic rhinitis, asthma attacks and food allergies.

The reimbursement of allergy treatments is only covered for 70% by the health insurance, which means that the intervention of a health insurance company is necessary to cover all or part of the personal contribution and possibly the deductible.

Disorders and illnesses during the holidays

A health insurance fund can provide assistance in the event of medical problems abroad, either by accompanying the patient in his steps or by organizing, if necessary, the repatriation of the insured person. These services are not automatic, it is therefore essential to check the guarantees on the contract before traveling.


Leave a Comment