JUDGMENT OF THE EUROPEAN UNION CIVIL SERVICE TRIBUNAL

(Third Chamber)

25 May 2016

GW

v

European Commission

‛Civil service — Officials — Social security — Reimbursement of medical expenses — Specific and thorough examination’

Application:

under Article 270 TFEU, applicable to the EAEC Treaty pursuant to Article 106a thereof, in which GW requests the Tribunal to annul the decision of the European Commission refusing to consider the costs in itemised accounts Nos 67 and 68 of 7 February 2014 and No 72 of 12 March 2014 relating to the healthcare of his wife (‘Mrs T.’) to be reimbursable.

Held:

The European Commission’s decision refusing to consider the costs in itemised accounts Nos 67 and 68 of 7 February 2014 and No 72 of 12 March 2014 relating to Mrs T’s healthcare to be reimbursable is annulled. The European Commission is ordered to bear its own costs and to pay the costs incurred by GW.

Summary

1. Actions brought by officials — Action against a decision rejecting a complaint — Effect — Contested measure referred to the Court — Condition — Statement of reasons for the rejection decision must be the same as for the contested measure

   (Staff Regulations, Arts 90 and 91)

2. Officials — Social security — Sickness insurance — Medical expenses — Reimbursement — Refusal — Treatments deemed to be non-functional or unnecessary — Refusal based on an opinion of the medical officer — Judicial review — Limits

   (Staff Regulations, Art. 72(1))

3. Officials — Social security — Sickness insurance — Medical expenses — Reimbursement — Obligations of the institutions — Observance of the principle of sound administration and the duty to have regard for the welfare of staff with regard to hospital expenses — Refusal to reimburse where it is possible to have outpatient treatment for medical services previously requiring hospitalisation — Scheme member responsible for proving that hospitalisation was necessary

   (Staff Regulations, Art. 72; Rules on sickness insurance, Arts 43, 49 and 52; Parliament and Council Regulation No 966/2012, Art. 30)

1.  Given its very purpose, which is to enable the administration to review its decision, the pre-litigation procedure is of an evolving nature, so that, in the scheme of legal remedies provided for in Articles 90 and 91 of the Staff Regulations, the administration may decide, when it rejects a complaint, to vary, in the light of that complaint, the grounds on which it had adopted the contested measure. None the less, it is certainly the legality of the original act adversely affecting an official that is being examined, in the light of the reasons contained in the decision rejecting the complaint. It follows that, where the Settlements Office refuses to reimburse certain medical expenses on the basis of a brief, unfavourable opinion of its medical officer and the official concerned lodges a complaint, the administration may, in response to that complaint, provide more explicit reasons during the pre-litigation procedure. Such specific reasons relating to the individual case, notified prior to the initiation of proceedings before the courts, are deemed to be identical to those for the decision to refuse reimbursement and must therefore be regarded as relevant information for assessing the lawfulness of that decision.

   (see para. 36)

   See:

   Judgment of 9 December 2009 in Commission v Birkhoff, T‑377/08 P, EU:T:2009:485, para. 56

   Judgment of 26 March 2014 in CP v Parliament, F‑8/13, EU:F:2014:44, para. 21 and the case-law cited therein

2.  With regard to sickness insurance, although a member of the Joint Sickness Insurance Scheme (JSIS) may legitimately consider that his medical expenses will, in principle, be reimbursed up to the ceilings laid down in Article 72(1) of the Staff Regulations, the reimbursement of certain costs may, however, lawfully be refused by the Settlements Office concerned if, after consulting the medical officer and, where appropriate, the Medical Council, the Office considers that those costs relate to treatment or services whose scientific validity is unproven. It is entirely justified that the cost of treatments or services whose therapeutic value or reliability as a diagnostic means is scientifically disputed should not be reimbursed by the JSIS, which is financed by its members and the institutions. It was in order to avoid endless or inextricable expert debate that the JSIS medical authorities — the medical officers and the Medical Council — were given the task of conducting appraisals in this context, their decisions being taken on the basis of the scientific literature, if necessary after consulting specialists or experts in the medical field in question.

   However, even if review by the Courts does not extend to specifically medical assessments, it must verify that the medical officer or Medical Council has conducted a specific and thorough examination of the situation presented to it, especially if the procedure does not offer the same level of safeguard in terms of balance between the parties as the procedures provided for by Articles 73 and 78 of the Staff Regulations. Furthermore, it is for the administration to establish that an assessment of this nature has been made. In carrying out their specific and thorough examination, the medical officers, Medical Council and the administration must take a decision on the basis of the scientific literature and, if necessary, after consulting specialists, but since an examination of whether or not a treatment or hospitalisation is functional is a medical question, they must also take full account of the actual state of health of the person concerned. Moreover, the obligation to take account of the personal situation of the JSIS member is dictated by the duty to have regard for the welfare of staff, which broadly coincides with the obligation to conduct a full and thorough examination. In that regard, the Medical Council has merely advisory powers, as is clear from Article 41 of the Joint rules on sickness insurance for officials of the European Union. A recommendation of the Medical Council does not constitute, as such, a rule applicable by the administration or, consequently, a rule enforceable against officials and other EU staff. That being so, the opinion of the Medical Council cannot bind a medical officer in such a way as to prevent him from considering whether or not a given treatment was ‘functional’ in the case in question.

   (see paras 38-40, 49, 50)

   See:

   Judgment of 9 December 2009 in Commission v Birkhoff, T‑377/08 P, EU:T:2009:485, paras 32, 61 and 88

   Judgments of 18 September 2007 in Botos v Commission, F‑10/07, EU:F:2007:161, paras 63 and 64; 8 July 2008 in Birkhoff v Commission, F‑76/07, EU:F:2008:95, para. 62, and 28 September 2011 in Allen v Commission, F‑23/10, EU:F:2011:162, para. 76

3.  Article 49 of the Joint rules on sickness insurance for officials of the European Union (the Insurance Rules), adopted on the basis of Article 72 of the Staff Regulations, provides that ‘the financial objective of the [Joint Sickness Insurance] Scheme [JSIS] shall be to ensure a balance … between expenditure and income’. Moreover, Article 43 of the Insurance Rules made Regulation No 966/2012 on the financial rules applicable to the general budget of the Union applicable by analogy to the management of the JSIS. According to Article 30 of that Regulation, the Commission, which is delegated by the other institutions to manage the JSIS, must administer expenditure and income in accordance with the principle of sound financial management, namely in accordance with the principles of economy, efficiency and effectiveness. In that context, Article 52 of the Insurance Rules entrusted the Commission with the task of laying down the rules governing the reimbursement of medical costs with a view to protecting the financial balance of the JSIS between expenditure and income. In accordance with the principle of sound administration, the Commission and, by extension, the Settlements Offices must therefore be careful not to commit JSIS funds rashly.

   From this point of view, medical advances and modern techniques now make it possible to offer outpatient treatment for medical services which previously required hospitalisation. In the light of this situation and the legal context applicable, it is the JSIS member’s responsibility to be mindful of these developments and to provide evidence of the need for hospitalisation where that need is disputed. In that regard, opinions expressed unilaterally by medical officers from the institutions under Article 72 of the Staff Regulations do not provide the same level of safeguard with regard to the balance between the parties as those produced by the Medical Committee or the Invalidity Committee on the basis of Article 73 of the Staff Regulations. That being so, holding that medical reports provided a posteriori are not conclusive as such would amount to denying JSIS members a basic means of defence capable of leading the administration to review its position.

   (see paras 53, 54, 60)

   See:

   Judgments of 28 September 2011 in Allen v Commission, F‑23/10, EU:F:2011:162, para. 69, and 16 May 2013 in de Pretis Cagnodo and Trampuz de Pretis Cagnodo v Commission, F‑104/10, EU:F:2013:64, paras 111 and 112