Judgment No. 2083
1. THE DECISION OF 26 JULY 2000 OF THE DIRECTOR-GENERAL IS SET ASIDE.
2. THE CASE IS SENT BACK TO THE ORGANIZATION FOR REFERRAL TO A MEDICAL BOARD IN ACCORDANCE WITH CONSIDERATION 10.
3. THE COMPLAINANT'S CLAIMS TO REIMBURSEMENT OF BILLS WHICH SHE DID NOT SUBMIT AND TO RESERVATION OF HER RIGHTS FOR FUTURE MEDICAL COSTS ARE DISMISSED.
4. THE ORGANIZATION SHALL PAY THE COMPLAINANT 3,000 SWISS FRANCS IN COSTS.
Considerations 8 and 9
The complainant suffered from retinal detachments and a detachment of the vitreous. The organization recognised her eye condition as service incurred. In "September 1998 [...] the [organization] decide[d] to stop reimbursing the bills [she submitted] on [the] grounds [...] that curing her retinal detachments was no longer the object of the treatment. However, it did not show that the service-incurred injuries were not a "direct and principal" cause of the treatment [... ] The Tribunal takes the view that although, as the organization says, the decision to stop reimbursing the bills was at the discretion of the Director-General, it could not be taken without an independent expert medical opinion obtained through a process which provides all the safeguards of transparency and impartiality." The case is therefore sent back to the organization.
procedure; complaint allowed; decision; grounds; organisation; case sent back to organisation; lack of evidence; expert inquiry; due process; independence; organisation's duties; accident; illness; insurance benefit; medical opinion; service-incurred; refund; discretion; executive head; consequence; refusal; safeguard