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Saturday, 24 February 2018 07:06

Local hospital charges for foreigners explained

Kaş Hospital Kaş Hospital

On 3rd February KTLN reported on the range of services now available at our local state hospital in Kaş and we also brought you news of some changes in the way in which the state operated health insurance (SGK) rules are being enforced.  Click here to read that report.

On the SGK changes we said that more research was required and that we would provide an update when we had discovered the facts.  Last week we had two separate meetings.  We spoke with Dr Ali İhsan Alpay, a senior manager at Esnaf private hospital in Fethiye and subsequently we went to Kaş Devlet (state) hospital and met with the person in charge, Dr Serdar Yılmaz and his finance manager. 

In this report we explain how charges work for foreigners in both state and private hospitals, whether they are tourists or expats, with or without health insurance.  Our main focus is on how things work for British citizens although we do have information that is useful for some other foreign nationals.

We should stress that our analysis reflects what happens at the two hospitals we visited.  The pricing principles will probably apply to hospitals in other places, but if you live in a different area and use other hospitals you may wish to make your own enquiries.  It is not uncommon in Turkey for different provinces to interpret rules and regulations in different ways - as we saw with GIYKIMBIL for example.

Different protocols
Turkey operates a system that allows private and state hospitals to work alongside each other providing health services.  So you have a choice where you want to be treated.  The quality of medical care provided in both private and state hospitals is good. 

Pricing procedures and principles differ between the two types of hospital.  Below we explain how these different protocols work in our area.  We start with how the rules work for tourists.

1. Tourists requiring medical treatment in Turkey

If you are here on holiday and you need to use the medical services generally speaking you will have to pay.  This is the case for treatment received at private hospitals and state hospitals.  The former tend to be more expensive than the latter. 

Medical bills can be expensive, especially if you are badly injured in an accident, so the clear advice is to take out holiday insurance that will cover most or all medical costs.  You should always read the small print to ensure you have the cover you need.  For example some travel insurance policies may not cover you for medical bills resulting from accidents that occur whilst participating in certain activities, such as quad biking or paragliding.  You may also find that your policy only covers you for treatment in state hospitals.

You get what you pay for.  If you go for a cheaper policy your cover may be inadequate and leave you with a bill to pay.  Choose your holiday insurance carefully.  Please read this excellent advice from the UK Foreign & Commonwealth Office: UK FCO advice - foreign travel insurance

The policy at Esnaf is to use travel insurance whenever possible for both outpatient and inpatient treatment.  The only occasions where they can’t use a tourist’s travel insurance is when a condition has not been declared on the policy; when the medical expenses come less than the policy excess; if the policy doesn’t cover private hospital treatment or in the event of an extreme sports accident where there has been no additional cover taken out for this.  Some other private hospitals work differently - for example, only accept travel insurance for inpatient treatment.  All patients pay their excess to the hospital.

112 ambulanceA&E ambulance call outs
Emergency 112 ambulances charge tourists for the distance travelled and for each intervention, however they are free to all residence permit (RP) holders, even without SGK.  Ambulances from private hospitals have set charges based on distance for both tourists and RP holders, but any extra interventions are not charged for.  Often private hospital ambulances can work out significantly cheaper for tourists compared to 112.

If you are involved in an accident and an Emergency 112 ambulance is called it will take you to the hospital that is best equipped to treat your condition.  For things like fractures and routine minor A&E injuries, if you are in the Kalkan area you will probably be taken to the state hospital in Kaş. 

In certain life critical cases it could be that you are taken to a private hospital in either Fethiye or Antalya, in which case the extent of cover afforded under your policy could be an issue.  If your policy only covers state hospitals you could find yourself in the invidious position of having to get clearance from your insurers in a stressful situation where time is of the essence.  Indeed if you are unconscious or unable to speak to the ambulance crew you won’t have any say in the matter.  The ambulance has a duty of care towards you which means they will take you to the most appropriate hospital.

A word of reassurance; in critical emergency situations first and foremost you will receive the treatment you need without having to worry about pre-paying.  Both private and state hospitals told us that the initial ambulance service, triage and any other time critical treatment (including the use of ICU services) will be provided without question, with any discussion on costs taking place after the emergency has been dealt with.

Please be aware that the European Health Insurance Card (which replaced the old form E111), is not valid in Turkey.

2. Expats with no health insurance

For all intents and purposes your situation is similar to that of a tourist on holiday.  If you are living in Turkey with no health insurance you are liable to pay all medical bills in full, whether at a private or state hospital.  If you have a serious medical condition the amount you may have to pay could be significant. 

Anecdotally we have heard of some instances where expats with no health cover have received medical treatment at very little cost.  This suggests to us that hospitals have some degree of flexibility in charging but we would not recommend relying on this.  If you have paid nothing in to the Turkish health system it is unreasonable to expect to get treatment for free.

3. Expats with private health insurance

A number of Turkish companies provide private health insurance (özel sigorta); for example Yapı Kredi, Allianz and Anadolu.  These policies operate in a similar way to those issued by UK companies you may be familiar with, such as Bupa, Aviva and AXA-PPP.

You can even find “international” health insurance policies where the insurer may be based outside Turkey, but is able to offer cover that works in various countries, including Turkey.

Typically private health insurance policies offer a range of cover options.  You choose the level of cover you require and pay the appropriate premium.  Clearly the more you pay the better the cover.

We understand that a basic insurance policy that an RP applicant can buy in order to get their RP provides cover for 60% of outpatient treatment costs and 100% of inpatient treatment costs.  However, this does depend on the diagnosis, the patient’s previous medical history and how long the policy has been in place for.  Of course there are more comprehensive policies available for a higher premium. 

It is not possible to say with any certainty what, if anything, you would have to pay in either a private or state hospital as it depends entirely on the cover you have paid for.  As with holiday insurance policies our advice is to read the small print - ideally before you need to use the policy.

SGK health insurance4. Expats with SGK health insurance

This is the scenario that has been provoking much interest and speculation over recent months.

As we will go on to explain, it’s our view that the rules and regulations concerning SGK (as set out in Law 5510 dated 31st May 2006) have not changed, however the way they are being implemented has.

We said earlier that we have a choice as to whether we go private or down the state hospital route.  First of all let’s look at what happens with charges at Esnaf private hospital in Fethiye.  Then we will take a look at how things work at Kaş state hospital.

4.1 Esnaf private hospital
Over recent years many expats with SGK have chosen to use private hospitals like Esnaf, for a variety of reasons.

Typically you pay a relatively small proportion of the bill and then Esnaf will claim back the rest from SGK.  However over the last six months or so the authorising SGK office (which for Esnaf is based in Izmir) has been pushing back on some claims and has refused to pay out.  This has resulted in patients being asked to pay the full amount of treatment costs.  We should make it clear that Esnaf hospital would explain the situation before asking for any payment. 

For any previously refused cases Esnaf hospital is not seeking to claim recompense from patients; they are agreeing to absorb this cost.  Only in approximately two thirds of cases where a patient has had surgery have they needed to request extra payment in order to cover the cost of materials used.

So what is going on?  Why are we seeing this new hard line from SGK? 

We have heard it said that private hospitals must be charging too much and SGK are trying to save money.  In fact all private hospitals are assessed by SGK and given a rating depending on the type of services they offer.  In Esnaf’s case they are an A rated hospital.  The amounts that they can claim back from SGK are agreed and set out in a detailed list of medical conditions, (defined by International Category of Disease [ICD] codes), and according to the hospital’s rating.  The hospital can not claim back more than the maximum permitted in the list, even if they have increased the prices they charge to private patients not claiming under SGK.

Pre-existing chronic conditions
The real reason for this new hard line is to do with how Article 64, paragraph C of Law No 5510 is applied.  It states that SGK will not pay for “Healthcare services for chronic sicknesses of foreigners which was present before the date they are deemed to be universal health insurance holders* or dependents of universal health insurance holders”.

* For the purposes of this article the term “Universal Health Insurance” and “SGK” are synonymous.

This English wording is taken from the official SGK web site, but we have seen the original Turkish wording too and there is no ambiguity.  If you develop a chronic illness after you joined SGK you are covered but if you had the illness before you joined you are not covered.  So the key points that arise are:

  • How to decide if it is a chronic illness, and
  • How to establish whether it was pre-existing or not?

If it is determined by SGK that your condition is both chronic and pre-existing, this is where the problems arise.

Definition of chronic illness
There is an internationally accepted view of what constitutes a chronic illness - also known as a Long Term Physical Health Condition.  The following link takes you to a UK NHS web site that explains it in English: NHS UK Data Dictionary - Long Term Physical Health Condition

Some examples would be Diabetes; COPD; Hypertension (High Blood Pressure); Angina; Arthritis; Cataracts; Thyroidism; IBS and Cancer.  This is not a definitive list, just some of the more common examples of chronic conditions.

It follows that if you are being treated for something that is not seen as a chronic illness, such as a bone fracture or similar A&E conditions that are temporary and can be fixed, then there is absolutely no issue - SGK will pay out in accordance with the price list agreed with the hospital.  For A&E scenarios you are effectively treated the same way as a Turkish citizen.

Is the condition pre-existing?
So identifying whether your condition is chronic is relatively straightforward.  The real issue here concerns how SGK decides if the condition is pre-existing.  In the past SGK officials have not placed too much emphasis on this, but for some reason they are now scrutinising claims more rigorously.

What we are seeing here is the SGK applying the strict letter of the law.  But it’s actually more than this because where it is not obvious whether a chronic condition is pre-existing or not SGK could well take the view that it is and decide not to pay out.  If you disagree with them the onus is on you to prove otherwise.

For many of us this is an example of where some perfectly innocuous action (or inaction) can come back to bite you on the gluteus maximus. 

When expats joined the SGK scheme many years ago there was vague reference somewhere online of needing a medical check up, but nobody in authority (at the SGK office or medical professionals) insisted on it, or ever mentioned it or explained that it was important.  Anecdotally we don’t know of anyone locally who had this medical check up when they joined SGK.  Nobody questioned why expats had not had these check ups.

It turns out that this medical check up is very important indeed because it provides you with definitive proof of your medical condition at the time you were accepted on to the SGK scheme.  The report would give you incontrovertible evidence as to whether you had any chronic illnesses.  If you had this report done and no chronic conditions were identified, SGK could not refuse to pay out for any chronic conditions that you may subsequently develop.

Obviously if the report did identify a chronic condition at the time you joined SGK, the scheme would not be obliged to pay for treatment of the condition(s).

SGK payments refused
Esnaf hospital has told us that over recent months SGK has refused to pay out on several claims for the treatment of chronic illnesses where they (SGK) consider it must be pre-existing. Patients must either pay the total cost of treatment from their own resources, or they have to prove to the satisfaction of the SGK officials that the chronic condition was not pre-existing.  Proving this can be a challenging and lengthy process at a time when the patient may be distressed and vulnerable. 

Proving a negative

Often it can be hard to prove a negative.  Without a medical check up at the time you joined SGK how can you prove you didn’t have a chronic condition back then? 

The passage of time can help.  If you joined SGK on 1st January 2017 (without having a check up) and then on 1st February 2017 you were diagnosed as having a chronic illness it may be quite reasonable to assume you had the condition when you joined.  The same could possibly be said if you were diagnosed later in 2017.

However if you joined SGK in 2012 and you are diagnosed with a chronic condition now in 2018 you may be able to refer to your medical notes to demonstrate that your condition is something new and could not possibly have been present and detectable back in 2012.  The problem remains that your argument is subjective and may depend on medical opinion, as well as the amount of time that has elapsed since you joined SGK.

Take something like cataracts for example.  This is a condition affecting the eye that takes several years to develop.  Often the condition may be detectable in its early stages but doctors may not intervene until vision is severely impaired.  How would you go about establishing when this condition started?  How could you prove it was not pre-existing?  You can imagine the difficulty here.

4.2 The state hospital in Kaş
The way in which medical treatment budgets are managed in state hospitals is completely different from the private sector.  Different pricing protocols apply.

The good news is that British expats with SGK will find that for the most part they are treated exactly the same way as Turkish citizens with SGK.  Most treatments are free or are subject to relatively small charges.

On the question of chronic illnesses we were told that they will treat foreigners who have SGK health insurance.  The question of whether it was a pre-existing chronic illness at the time of joining the SGK scheme is not something they are concerned about.  So in as much as it is possible to get all the treatment you need at our local state hospital everything is fine.  You will pay no more than a Turkish citizen would pay.

However if the doctors at Kaş state hospital were to make a clinical assessment that you would receive more effective treatment in a private hospital - because for example they have more experienced specialists or access to better equipment, then the issue of pre-existing conditions would have to be dealt with at the time of your referral.

What advice is there for those who never had the check up on joining SGK?

We asked senior doctors at Esnaf and at the Kaş state hospital what British expats should do if they failed to get a medical check up when they joined SGK.  Their advice was to get one done as soon as possible.  It’s actually called a “Sağlık Kurulu Raporu” or a “Heyet Raporu”.  Roughly translated, a “Health Board Report”.

Even though it may be late in the day it will draw a line in the sand and will provide you with the proof you need in relation to possible future claims on SGK concerning treatment for any chronic illnesses you may develop in later life.  Of course if you are already suffering from a chronic condition it will not help in this regard.

These check ups can take place at either Kaş state hospital or the state hospital in Fethiye.  There is a charge of 200 TL (in 2018) for performing the check up and issuing a report.  You need to take along your ikamet plastic card as ID, and 4 passport sized photographs.  Keep your report in a safe place. 

If you tend to use a particular private hospital it may be helpful to send them your Health Board Report once you have obtained it.  If they have your report on file it will help when the hospital has to seek SGK funding.  For people who use Esnaf private hospital in Fethiye you can take a photo of your report and send it to this email address: This email address is being protected from spambots. You need JavaScript enabled to view it.

Other points of interest

Below we outline a few notable points not already covered above.

Local doctors - Kalkan Family Medical Centre

Just a brief word about our local GPs who operate within the state health service.  They are there to serve the local community and operate in a similar way to GPs back in the UK.  Residents (Turkish and foreign residents) register with their GP and can make appointments to see them.

There is no obligation for GPs to see tourists.  The proper route is to go to the A&E department of your nearest hospital, or if it is something fairly minor (like an upset stomach) you could always ask advice from a chemist.  Having said that a doctor’s primary instinct is always to treat anyone who is ill.  We know that our local GPs will try to be helpful and if they have time it may be possible to get a consultation.

Also in Kalkan we have one private doctor, Dr Niyazi Öncüler.  His private surgery is on Kalamar Road.  Anyone can go to him for a consultation but you must pay. 

Price lists for residents with SGK and for tourists

The following link takes you to an official government web site where you can find the current standard price list applicable at state hospitals.  The list is extensive and fairly comprehensive.  Please note these prices do not apply to private hospitals.  Health Service Tariffs

Once you have clicked on the above link select the appropriate tariff.  (An Excel spreadsheet will be downloaded to your computer).


e-Devlet and e-Nabiz
Foreign residents of Turkey with a kimlik number (starting 99…) are able to register on the e-Devlet system - an online portal that gives access to a number of government databases where you can see information held in your name.  You can check things like your registered address, your property (tapu) details and vehicles in your name. 

There is another database you can access via e-Devlet, which provides instant access to your Turkish medical records.  This is called e-Nabiz (Nabız is Turkish for “pulse”).  Please note it does not contain details held by private hospitals - only state hospitals and medical centres.  You can check your medical history including details of medicines prescribed. 

Both e-Devlet and e-Nabiz are free to use.  They are in Turkish only - there are no pages in English, although using the Google Chrome web browser can provide a rudimentary attempt at translation.

Reciprocal arrangements between Turkey and other countries - YUPASS
The UK has no reciprocal arrangement with Turkey on health care.

However if you are a citizen of Austria; Belgium; France; Germany or Holland (there may be others we don’t know about) you will be pleased to know that your governments have got reciprocal arrangements in place, which means that you will receive the same treatment as a Turkish citizen in Turkey.  It’s a bit like having SGK but without the need to pay any premium here in Turkey.

This is possible because Turkey claims back the cost of any treatment from the citizen’s country of origin.  This arrangement assumes that back in your own country you have made the necessary contributions to your health service.  Obviously it works in reverse, so Turkish citizens living in these countries benefit too.

For the countries listed above the reciprocal deal is known as Yurtdışı Provizyon Aktivasyon ve Sağlık Sistemi (YUPASS).  To benefit from this arrangement you must first of all obtain a document from your home country that shows your entitlement to health services.  You then present this to your local SGK office here in Turkey, who will verify the details and issue you with a YUPASS number.  This number is held on a Turkish health service database so when you require medical services the staff will be aware that you are entitled to free treatment.

UK citizens - YU-DON'T-PASS
You might be asking why the UK is not part of the YUPASS scheme.

The enlightened countries listed above appear to have recognised that reciprocity is a good thing when it comes to health services.  Their citizens have contributed to the healthcare system through a lifetime’s payment of taxes so it’s only fair that they should get the benefits they have already paid for, even though they have moved to Turkey. 

It seems to us (and indeed the countries listed above) that it is a morally questionable position to penalise citizens for their life choices by taking their taxes and leaving them high and dry when they need medical services.  Its a reminder of the extent to which some governments are lagging behind in developing and adapting services for the way in which some people choose to live their lives in the twenty first century.

Perhaps British expats in Turkey should be asking the UK government why we don’t have YUPASS.

Your feedback
As always KTLN welcomes your feedback.  If you have any experience of using the health service in Turkey please feel free to tell us what happened - good or bad.  If we want to share your feedback with our readers in any articles we publish we will ask for your permission first and we guarantee not to disclose any details that would identify you personally.  Click here to contact KTLN. 


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