Judgment No. 1148
Decision
THE COMPLAINTS ARE DISMISSED.
Considerations 12-13
Extract:
Having submitted a claim for the refund of the costs of an item, the complainant first received a statement from the Sickness Fund which alluded to "non-refundable items". Only later did a note indicate which items were being refused. Eurocontrol contends that the time limit ran from the date at which she got the original statement from the Fund, the later note having merely confirmed the earlier decision. "The argument fails. The cryptic allusion in the statement to 'non-refundable items' did not suffice to tell the complainant just what she was being refused. The 'act adversely affecting' her - to quote the Regulations - did not become specific until she got the [note] and so that is the date at which the time limit for her internal appeal began. [...] She acted in time."
Keywords
decision; confirmatory decision; time limit; start of time limit; refund; medical expenses; health insurance
Consideration 18
Extract:
The complainant is challenging [the organisation's] Sickness Fund's refusal to refund the cost of an item classified as "phytotherapy". The Tribunal holds that "under Article 14 the administration may determine whether an item that a fund member wants to have refunded is a 'pharmaceutical product' within the meaning of the rule. [...] That is a matter of medical opinion and among the relevant criteria are the preventive or therapeutic efficacy of the product, scientific inquiry into the effects it has, and any risks involved in using it. So decisions by public health bodies are highly relevant, particularly for an international fund like [the organisation's] that covers more than one country and allows free choice of practitioner."
Reference(s)
Organization rules reference: ARTICLE 14 OF RULE 10
Keywords
domestic law; freedom to choose practitioner; insurance benefits; discretion; medical expenses; health insurance
Consideration 21
Extract:
The complainant objects to the refusal by Eurocontrol's Sickness Fund of her claim to the refund of costs incurred for treatment. The organisation notified this decision to her by an office memorandum and it constituted an individual decision. "The organisation [...] has wide discretion in the matter and may exercise it as it sees fit for the purpose of ensuring the efficiency and financial soundness of its fund. There is more than one legal procedure it may resort to. It may adopt general rules [...] or else it may take individual decisions on particular cases."
Keywords
general decision; individual decision; administrative instruction; discretion; medical expenses; health insurance
Consideration 19
Extract:
The complainant objects to the Sickness Fund's refusal to refund the costs of a product which her doctor prescribed and which she bought in a pharmacy. The Tribunal holds that the fact "that a product has been bought in a pharmacy [is immaterial] since a pharmacy may sell many health items that are not products within the meaning of the rule. Likewise a doctor's prescription is no criterion since according to the rule it is a condition of refund over and above the objective effects of the product."
Keywords
freedom to choose practitioner; discretion; medical expenses; health insurance
Consideration 20
Extract:
The complainant objects to the Sickness Fund's refusal to refund the costs of a given item. "Eurocontrol has [...] discretion under Article 24, which empowers the fund to refuse refund of the costs of treatment which the medical officer deems to be 'non-functional, superfluous or unnecessary'. As was said in Judgment 1088, [article] 24 covers all sorts of 'treatments', however the term 'pharmaceutical product' in [article] 14 is to be construed."
Reference(s)
Organization rules reference: ARTICLES 14 AND 24 OF RULE 10
Jugement(s) TAOIT: 1088
Keywords
insurance; medical consultant; refund; discretion; limits; definition; refusal; medical expenses; health insurance
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