Judgment No. 3158
1. The decision of the President of the Office of 11 November 2009 is set aside and the case is remitted to the EPO for a redetermination as detailed under 9.
2. The EPO shall pay the complainant moral damages in the amount of 700 euros.
3. It shall also pay him 600 euros in costs.
4. All other claims are dismissed.
The complainant successfully challenges the lawfulness of the decision not to reimburse the pharmaceutical products prescribed by his doctor.
"[T]he complainant only became aware of the substitution of one of the members of the Internal Appeals Committee (which occurred after the hearings) when he received a copy of the Internal Appeals Committee’s opinion. For the sake of transparency and due process, the complainant should have been informed at the time of the substitution so that he could exercise his right to contest the composition. The fact that the alternate member voted in the complainant’s favour does not redeem that flaw. Moreover, the alternate member did not attend and participate in the hearing, whereas his participation could have changed or influenced the Internal Appeals Committee’s final opinion."
internal appeals body; advisory body; internal appeal; right to reply; due process; organisation's duties; duty to inform; flaw; procedural flaw; consequence; composition of the internal appeals body
"[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]."
interpretation; insurance; medical expenses; health insurance
"[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 [...]."
Organization rules reference: Articles 83 and 90 of Service Regulations
advisory body; staff regulations and rules; interpretation; medical board; medical expenses; health insurance
complaint allowed; decision quashed; case sent back to organisation; medical expenses; health insurance