Although European groups have initiated innovative clinical research in the field of insulin pump therapy, insulin pump use remains currently limited in many European countries, and well behind that in the United States. The main reason is the late approval of cost coverage by most national healthcare insurance systems, which is still lacking in some countries. Partly in connection with this delay, the number of trained physicians to pump therapy is low in many countries, while diabetes educators do not exist as an acknowledged entity in many European countries, and pump manufacturers are excluded from the education process of patients in most of them. Pump use in pediatric-age populations has strongly increased during the last years, following the evidence-based demonstrations of the benefits of pump therapy in these patients leading to an international consensus on pump indications and practice. Failure to control type 1 diabetes to target and frequent hypoglycemia under multiple daily insulin injections are consensus-based but restrictive indications for pump therapy in adults in most countries. The economic burden on healthcare insurance systems does not facilitate wider use of insulin pumps, but a significant expansion of pump therapy according to consensus-based indications is still expected thanks to the growing knowledge of physicians in technologies and because of the increasing interest of patients to use technology to improve their control of diabetes and health-related quality of life. More sophisticated technologies connected to pump therapy, such as continuous glucose monitoring or telemedicine, will need specific cost coverage for a true implementation in diabetes care in Europe.