Judgment 3491
120th Session, 2015
International Atomic Energy Agency
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Summary: The complainant, who suffered service-incurred injuries and engaged in swimming therapy, impugns the decision to only partially reimburse the cost of her gym membership.
Judgment keywords
Keywords:
complaint allowed; decision quashed; health insurance; joinder; medical expenses; service-incurred; sick leave;
Judgment 3361
118th Session, 2014
European Organisation for the Safety of Air Navigation
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Summary: The complainant successfully impugns the decision rejecting her request seeking payment of the costs of an orthodontic treatment and a surgical operation.
Judgment keywords
Keywords:
case sent back to organisation; complaint allowed; health insurance; medical expenses;
Judgment 3354
118th Session, 2014
European Patent Organisation
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Summary: The Tribunal set aside the decision dismissing the complainant’s request for the reimbursement of pharmaceutical costs on the ground that the case should have been referred to the Medical Committee.
Judgment keywords
Keywords:
case sent back to organisation; complaint allowed; decision quashed; health insurance; medical expenses;
Judgment 3218
115th Session, 2013
European Organisation for the Safety of Air Navigation
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Summary: The complainant challenges his registration with the new office in charge of the sickness insurance scheme.
Judgment keywords
Keywords:
complaint dismissed; health insurance; insurance; medical expenses;
Judgment 3158
114th Session, 2013
European Patent Organisation
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Summary: The complainant successfully challenges the lawfulness of the decision not to reimburse the pharmaceutical products prescribed by his doctor.
Judgment keywords
Keywords:
case sent back to organisation; complaint allowed; decision quashed; health insurance; medical expenses;
Consideration 6
Extract:
"[T]he conditions listed in the explanatory note of 20 October 2000 involve an interpretation of both 'generally accepted medical treatment' and 'proven therapeutic effects', in order to determine what constitutes 'medicines' for the purpose of Article 20(b)(2) of the [Collective Insurance Contract]. The Tribunal considers that such an interpretation implies a medical opinion. Accordingly, the questions of whether the products prescribed for the use of the complainant are 'medicines' for the purpose of the insurance policy and whether the complainant is entitled to be reimbursed under the policy consistent with his rights under Article 83 of the Service Regulations, require a medical opinion. As a result, these questions have to be referred to the Medical Committee in accordance with Article 90(1), paragraph 2 [...]."
Reference(s)
Organization rules reference: Articles 83 and 90 of Service Regulations
Keywords:
advisory body; health insurance; interpretation; medical board; medical expenses; staff regulations and rules;
Consideration 5
Extract:
"[T]he consensus between the Office and the insurance broker contained in the explanatory note of 20 October 2000
[...] should not be considered as binding, since it merely establishes guidelines interpreting the term 'medicines' as contained in Article 20(b)(2) of the [Collective Insurance Contract]."
Keywords:
health insurance; insurance; interpretation; medical expenses;
Judgment 3019
111th Session, 2011
European Patent Organisation
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Consideration 7
Extract:
Automatic coverage of spouses under the Organisation's long-term health insurance / Obligation to file a waiver declaration.
"The automatic coverage applied by the Implementing Rules cannot be deemed unreasonable. It is clear that under the system chosen by the Organisation some staff members may be slightly financially penalised if they fail to opt out of the scheme, as their automatic coverage will entail consequent deductions from their salaries. However, in evaluating the possible outcome resulting from automatic coverage and that resulting from a lack of coverage, the Organisation evidently considered that the outcome could be worse in the latter situation as staff members who neglected to enrol their spouses in the long-term care insurance scheme could suffer the severe financial consequences of not being insured when the need arose, and the Tribunal cannot regard the Organisation's choice as unreasonable."
Keywords:
deduction; dependant; health insurance; insurance; medical expenses; organisation; practice; salary; social benefits;
Judgment 2976
110th Session, 2011
European Patent Organisation
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Consideration 10
Extract:
"[I]n Judgment 2533 the Tribunal observed that compensation for injury properly included 'past and future adaptations to the complainant's house and car' and that those expenses were 'on no different footing than other necessary expenses incurred as a consequence of [...] service related injury'."
Reference(s)
ILOAT Judgment(s): 2533
Keywords:
compensation; definition; disability benefit; health insurance; injury; insurance; medical expenses; service-incurred;
Consideration 11
Extract:
"The purpose of insurance is to indemnify, whether in whole or in part, and not simply to provide a social safety net."
Keywords:
compensation; health insurance; insurance; medical expenses; purpose;
Judgment 2533
101st Session, 2006
Organisation for the Prohibition of Chemical Weapons
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Consideration 26
Extract:
The complainant suffered a workplace injury at the Organization premises. The results of this seemingly minor accident were catastrophic and the complainant is now permanently and totally disabled and suffers from a rare illness, which has extended up both of the complainant's legs and requires him to use a wheelchair.
"[G]iven the possibly progressive nature of [the illness], the condition may continue to deteriorate seriously. [...] the Tribunal asserts unequivocally that the defendant's obligation to pay the complainant reasonable compensation for the results of his workplace injury is a continuing one and is not affected or diminished by the terms of an insurance policy to which the complainant is not a party."
Keywords:
consequence; disability benefit; handicapped person; health insurance; illness; insurance; invalidity; maximum limit; medical examination; organisation's duties; professional accident; provision; service-incurred;
Consideration 18
Extract:
The complainant suffered a workplace injury at the Organization premises. The results of this seemingly minor accident were catastrophic and the complainant is now permanently and totally disabled and suffers from a rare illness, which has extended up both of the complainant's legs and requires him to use a wheelchair.
"[T]he expenses of necessary adaptations to house and car are on no different footing than other necessary expenses incurred as a consequence of the complainant's service-related injury and must be reimbursed."
Keywords:
handicapped person; health insurance; invalidity; medical expenses; organisation's duties; professional accident; refund; service-incurred;
Judgment 2449
99th Session, 2005
International Labour Organization
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Judgment keywords
Keywords:
complaint dismissed; en banc review; health insurance; plenary judgment; same-sex partnership;
Judgment 2290
96th Session, 2004
European Patent Organisation
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Consideration 3
Extract:
The Organisation contends that the internal appeal against a decision not to refund medical costs was not lodged in time. In doing so, it takes as the starting point of the time-limit the insurance representative's statement of account rejecting the request for refund. This "plea [...] is unfounded [...] This is because the insurance representative is not an organ of the Organisation, able to take decisions in the meaning of the Office's Service Regulations for Permanent Employees. Decisions concerning insurance benefits are taken by the Office, and more specifically by its President, in accordance with Article 83 of those Regulations."
Reference(s)
Organization rules reference: Article 83 of the Service Regulations for Permanent Employees of the European Patent Office
Keywords:
complaint; decision; executive head; health insurance; illness; insurance; internal appeal; medical expenses; receivability of the complaint; staff regulations and rules; start of time limit; time bar; time limit;
Judgment 2063
91st Session, 2001
European Patent Organisation
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Consideration 8
Extract:
"The Tribunal is fully competent to consider whether the Office is right in maintaining that [the insurance broker] Van Breda correctly exercised its authority in rejecting the request to meet the cost of transferring the complainant to a convalescent home."
Keywords:
competence of tribunal; discretion; health insurance; judicial review; refund; refusal; request by a party;
Consideration 8
Extract:
"The authority of the insurance brokers goes beyond a simple right to make an administrative check of the claims it receives [...]. [Insurers] have the right to check whether, under the insurance contract, they are liable for the costs of the care dispensed. But they must so exercise that authority as to provide the insured with a guarantee that their claims to coverage are examined with all due care."
Keywords:
condition; contract; discretion; duty of care; health insurance; insurance; medical expenses; refund; request by a party; safeguard;
Consideration 8
Extract:
After the complainant underwent surgery, the insurance brokers refused to cover his convalescence in a home. "In order to assess any physical injury suffered by the complainant, it is necessary to ascertain the later consequences for his health of the refusal to meet the costs of his admission to a convalescent home, and the fact that he did not as a result stay in such a home. These are purely medical matters which [...] need to be referred to the Invalidity Committee".
Keywords:
claim; competence; consequence; health insurance; illness; medical board; medical expenses; receivability of the complaint; refund; refusal; request by a party;
Judgment 2008
90th Session, 2001
European Organization for Nuclear Research
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Consideration 4
Extract:
"[The organization] submits that the Tribunal is not competent to entertain the complaint because, having left [the organization] many years ago the complainant is not in a position to assert any statutory or contractual rights: he benefited from a special extra-statutory arrangement made ex gratia and may not assert for his family any right arising under the terms of his appointment. The objection to the Tribunal's jurisdiction fails: [the organization] allowed its former employee to retain coverage by a health insurance scheme which he had originally been able to join only because of his employment relationship with [it]. Whether the continued protection he was granted albeit ex gratia may also be extended to his family can be determined only by ascertaining his rights as a former employee of the organization."
Keywords:
competence of tribunal; complainant; ex gratia; extension of contract; health insurance; locus standi; medical expenses; receivability of the complaint; right; status of complainant; tribunal;
Judgment 1917
88th Session, 2000
European Southern Observatory
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Considerations 7-8
Extract:
The Tribunal noted that since 1974 the health insurance contract has always been concluded for periods of one year and has even been amended several times. It does not agree that the complainant has an absolute claim to a specific system of health insurance, therefore, there has been no impairment of an acquired right.
Keywords:
acquired right; amendment to the rules; health insurance; insurance; staff member's interest;
Judgment 1904
88th Session, 2000
World Health Organization
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Summary
Extract:
When the Tribunal gives an organisation the choice to either reinstate a complainant or pay damages, and the organisation chooses to pay damages, it does not have to pay the contributions of the pension fund or the staff health insurance.
Keywords:
allowance; contribution rate; contributions; health insurance; illness; insurance; judgment of the tribunal; material damages; pension; reconstruction of career; reinstatement; unjspf;
Judgment 1894
88th Session, 2000
European Patent Organisation
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Consideration 5
Extract:
"It is not for the complainant [...] to judge whether the information requested by [the insurance company] is necessary in order to enable it to assess her claims. That is a matter for the professional assessment of [the insurance company] and its medical adviser and the Tribunal would not interfere unless it was satisfied that the information was being sought for some abusive or improper purpose."
Keywords:
evidence; good faith; health insurance; illness; insurance; judicial review; limits; medical examination; medical expenses; staff member's duties; tribunal;
Judgment 1880
87th Session, 1999
European Organisation for the Safety of Air Navigation
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Consideration 8
Extract:
"According to precedent [...] (see Judgments 1094 [...] and 1095 [...]), coverage at the rate of 100 per cent does not mean that in all circumstances an insured person is entitled to full repayment of expenses incurred. [T]o allow the [sickness] fund not to reimburse the part of the expenses deemed to be excessive is in keeping with the purpose of sickness insurance and it is a means of ensuring sound financing and comparable coverage for the beneficiaries, and as such falls within the authority delegated to the Director General. The reimbursement of expenses can be restricted by setting maximum limits or ceilings for certain types of expenditure or by reckoning limits for each case on the basis of costs incurred."
Reference(s)
Organization rules reference: ARTICLE 72 OF EUROCONTROL STAFF REGULATIONS
ILOAT Judgment(s): 1094, 1095
Keywords:
case law; health insurance; illness; insurance; limits; maximum limit; medical expenses; purpose;
Judgment 1848
87th Session, 1999
European Patent Organisation
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Consideration 12
Extract:
The complainant questions the right of the insurance company to which she is affiliated to contact her physicians directly to seek information. "The law is clear that [the insurance company] is entitled to any information which identifies the nature of the alleged illness and allows it to determine whether the prescribed treatment is appropriate and necessary [...] Of course the complainant is entitled to require that such information only be made available to [the insurance company's] medical adviser and be treated by the latter in confidence but she is not entitled to withhold from them any right of access whatsoever to the required medical information. Her unwillingness to allow such access goes against her duty to deal in good faith with her insurers."
Reference(s)
ILOAT Judgment(s): 1288
Keywords:
conduct; confidential evidence; elements; good faith; health insurance; illness; insurance; medical consultant; medical records; refusal; safeguard; staff member's duties;
Judgment 1797
86th Session, 1999
World Health Organization
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Considerations 12-13
Extract:
"The Organization pleads that it is under no duty to pay contributions for [the complainant] to the Pension Fund or to the staff health insurance plan and would have had such duty only if he had been reinstated [...]. The Tribunal ruled on a similar issue in Judgment 1338 [...], in which it held that its award [...] of damages equivalent to 'the amount of the salary, allowances and other entitlements [the complainant] would have received' had not required reinstatement in the Pension Fund or health insurance."
Reference(s)
ILOAT Judgment(s): 1338
Keywords:
allowance; application for execution; case law; contribution rate; contributions; enforcement; health insurance; insurance; judgment of the tribunal; organisation's duties; reinstatement; salary; social benefits; unjspf;
Judgment 1536
81st Session, 1996
United Nations Educational, Scientific and Cultural Organization
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Consideration 16
Extract:
The complainant seeks admission to the health insurance fund two years after his retirement even though the time limit for such claims is three months. "The answer to the complainant's plea of breach of equality is that the admission of the other retired official as an associate participant was a wrong decision. It should not be followed, and the board of management was right to refuse to follow it. Equality of treatment means equality in the observance of the law, not in the breach of it."
Keywords:
definition; equal treatment; general principle; health insurance; illness; insurance; retirement; time limit;
Judgment 1519
81st Session, 1996
United Nations Educational, Scientific and Cultural Organization
Extracts: EN,
FR
Full Judgment Text: EN,
FR
Consideration 12
Extract:
The International Civil Service Commission was not "bound to recommend that [the organization] fall in line with the practice of outside employers [...] In respect of compulsory insurance premiums and the refund of expenses incurred [the organization's] scheme of staff health insurance and the [national] social security system [...] are not closely comparable; indeed they are quite different. [...] The Commission abided by the applicable methodology - for all its flaws on that count - and [the organization] made no mistake of fact or of law."
Keywords:
contributions; flemming principle; general service category; health insurance; icsc decision; inquiry; insurance; investigation; salary; social benefits; terms of appointment;
