JUDGMENT OF THE COURT OF FIRST INSTANCE (Third Chamber)

12 May 2004

Case T-191/01

André Hecq

v

Commission of the European Communities

(Officials – Social security – Article 72(1) of the Staff Regulations – Reimbursement of medical expenses – Serious illness – Refusal to reimburse at 100% certain medical services)

Full text in French II - 0000

Application:         for annulment of two decisions adopted by the office responsible for the settlement of claims on 13 October 2000 and 6 November 2000, respectively, refusing to reimburse at 100% certain medical services provided for the applicant’s wife.

Held:         The decisions adopted by the office responsible for the settlement of claims are annulled in so far as they refuse to reimburse at 100% certain medical services provided for the applicant’s wife. The Commission is ordered to pay the costs.

Summary

1.     Officials – Social security – Sickness insurance – Medical expenses – Serious illness – Reimbursement at 100% – Conditions – Direct link between the medical expenses and the illness in question

(Staff Regulations, Art. 72(1); Rules on Sickness Insurance, Annex I, Section IV)

2.     Officials – Social security – Sickness insurance – Medical expenses – Serious illness – Reimbursement at 100% of screening costs regardless of the outcome of the screening

(Staff Regulations, Art. 72(1))

3.     Officials – Social security – Sickness insurance – Medical expenses – Serious illness – Reimbursement at 100% of medical expenses incurred with the aim of determining the origin of disorders possibly linked to a serious illness

(Staff Regulations, Art. 72(1))

4.     Officials – Social security – Sickness insurance – Medical expenses – Reimbursement – Refusal – Judicial review – Limit – Calling into question of regular medical assessments

(Staff Regulations, Art. 72)

5.     Officials – Social security – Sickness insurance – Medical expenses – Serious illness – Reimbursement at 100% – Requirement for a link between the medical expenses and the illness in question – Burden of proof on the official – Limit

(Staff Regulations, Art. 72)

1.     Under the terms of the Rules on Sickness Insurance for Officials of the Communities, as provided for in Article 72(1) of the Staff Regulations and Section IV of Annex I to the rules, the rate of reimbursement of medical expenses is 100% in the case of serious illness.

Article 72(1) of the Staff Regulations leaves it to the authors of those rules to define the scope of the insurance cover in question, in keeping with the Staff Regulations and the objectives which they pursue.

It follows that an interpretation of the provisions of the Staff Regulations to the effect that only medical expenses directly linked to the illness in question are reimbursed at 100% is consistent both with the intention of the legislature that only expenses linked to the treatment of a serious illness should be reimbursed in full, and with the nature of those provisions as a derogation from the principle of reimbursement at 80% or 85%.

(see paras 44-47)

See: 339/85 Brunotti v Commission [1988] ECR 1379, para. 10; T‑6/92 and T‑52/92 Reinarz v Commission [1993] ECR II-1047, para. 73

2.     By the very fact that, pursuant to Article 72 of the Staff Regulations, the costs of screening for serious illnesses are reimbursed at 100%, full reimbursement applies for medical examinations which, since their aim is to ascertain whether a serious illness exists, may reveal that there is no such illness present. The aim of that provision is thus to encourage screening for serious illnesses in order to ensure effective treatment at an early stage, thereby helping to prevent both the development of serious illnesses in the interests of the patient, and higher treatment costs for the Joint Sickness Insurance Scheme.

That approach is particularly necessary where the patient already has a serious illness that is recognised by the Community institutions. In such a case, it must be accepted a fortiori that doctors are justified in prescribing all the examinations necessary to verify whether the disorders suffered by the patient indicate a recurrence of that illness.

(see paras 54-55)

3.     Reimbursement at 100% as provided for in Article 72(1) of the Staff Regulations relates not just to medical expenses incurred for the treatment of a serious illness, but more widely to all medical expenses directly linked to such an illness. It also applies to medical expenses incurred with the aim of determining the origin of disorders that may be directly linked to such an illness.

It follows that the exclusion from 100% reimbursement of expenses incurred in determining the origin of disorders which may be linked to a serious illness solely because the results of those examinations do not establish such a link with certainty, even though at the time when the examinations are carried out the doctors do not, by definition, know the origin of the disorders, would be contrary to the requirement for effective preventive medicine and, consequently, to the sound management of the health protection scheme provided for in the Staff Regulations, in keeping with the aim pursued by Article 72(1) of the Staff Regulations.

(see paras 56-57, 106)

See: T-25/01 Viana França v Commission [2002] ECR-SC I-A-185 and II-951, paras 58 and 59

4.     The remedies provided for by the Staff Regulations may not generally be employed in order to challenge medical appraisals properly so-called, which must be regarded as definitive provided that the conditions in which they are made are not irregular. That does not mean, however, that the Court may not examine, without questioning the medical appraisals, whether, in a specific case, a refusal to reimburse medical expenses corresponds to a proper assessment of the facts and the correct application of the relevant provisions.

(see paras 62-63)

See: 2/87 Biedermann v Court of Auditors [1988] ECR 143, para. 8; T-33/89 and T-74/89 Blackman v Parliament [1993] ECR II-249, para. 44; T-199/01 G v Commission [2002] ECR-SC I‑A‑207 and II-1085, para. 59

5.     An official cannot be expected to establish a definite link between medical examinations and a serious illness in order to prove satisfactorily that such a link exists, since such proof may, in most cases, be scientifically impossible to provide; he may only be expected to establish with a sufficient degree of probability that such a link exists on the basis of a series of specific and consistent factors.

(see para. 81)