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Medical expenses (678,-666)

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Keywords: Medical expenses
Total judgments found: 50

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  • Judgment 2063


    91st Session, 2001
    European Patent Organisation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    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 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 1226


    74th Session, 1993
    Food and Agriculture Organization of the United Nations
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Considerations 3, 7 and 8

    Extract:

    The complainants challenge decisions by the Director-General confirming the abolition of free after-service medical cover. They allege breach of acquired rights and contend that the FAO's financial position did not warrant such measures. "The Tribunal will not compare the options open to the FAO in the area of financial policy since it might ignore the realities that the FAO has to take into account. All the Tribunal need do is acknowledge that it was because of the financial plight of the scheme and its own that the organization decided to do away with free coverage for pensioners. The change does cause the complainants detriment. [...] But that alone does not amount to breach of any acquired right. First, the effect of the change was to put all fao pensioners on a par. [...] Secondly, there were transitional measures to lighten the impact of the change [...]. Since the change was made by way of rules, and because of the reasons for it, the complainants have suffered no breach of any acquired right despite the injury to their interests."

    Keywords:

    acquired right; amendment to the rules; budgetary reasons; discretion; grounds; health insurance; insurance; judicial review; limits; medical expenses; organisation's interest; social benefits; staff regulations and rules;



  • Judgment 1186


    73rd Session, 1992
    Food and Agriculture Organization of the United Nations
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Consideration 7

    Extract:

    The complainants object to the abolition of free after-service health insurance cover. They contend that as serving officials they contributed to a health scheme that covered both their own medical expenses and those of former officials. The FAO's answer is that they never contributed to a health scheme that was intended to cover the expenses incurred both by serving and by retired officials. "The complainants are mistaken: as to medical insurance coverage their position before retirement was distinct from their position after it and amendments in the terms of their coverage after they had left had no retroactive effect on their earlier coverage."

    Keywords:

    amendment to the rules; further submissions; health insurance; illness; insurance; medical expenses; non-retroactivity; separation from service;



  • Judgment 1180


    73rd Session, 1992
    European Organisation for the Safety of Air Navigation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Considerations 2-3

    Extract:

    The complainant received treatment in a clinic. He had an operation and on that account spent five days in the clinic's department of surgery. The organisation agreed to refund the costs of his operation and the five-day hospital stay which it entailed. However it refused to regard the remainder of his stay in the clinic as "hospitalisation" and treated it as "a cure at a watering place". The material issue is whether that decision was lawful. "The Tribunal is satisfied that the Director General was right to decide that the complainant's stay at the clinic did not warrant the refund of his costs at the 'hospitalisation' rate [...] and that to regard but five days of that stay as 'a cure at a watering place' rather than hospitalisation for medical treatment was in line with the material rules."

    Keywords:

    cure; health insurance; illness; medical expenses; refund;



  • Judgment 1176


    73rd Session, 1992
    European Organisation for the Safety of Air Navigation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Consideration 12

    Extract:

    "Treating a person as a dependent child of the staff member in accordance with [the material provisions] confers health insurance coverage ipso facto on that person. [...] Eurocontrol must consider the consequences its decision [to treat someone as a dependent child] will have for insurance coverage."

    Keywords:

    dependant; dependent child; health insurance; illness; insurance; medical expenses; organisation's duties;

    Considerations 11 and 13

    Extract:

    Eurocontrol asked the complainant to supply proof that the dependant for whom he was seeking health insurance had no means of gaining cover for sickness under another public health scheme in keeping with Article 2(2) of Rule No. 10 of the Staff Regulations. "But since what is required is disproof - viz. proof that there is no coverage under this or that scheme - Eurocontrol may not consistently lay the burden on the insured member. If it did so, there would be a danger of making the rule unworkable. A fortiori it may not, after duly determining on all the material evidence at its disposal that someone may be treated as a dependent child, raise the question of possible coverage by another public scheme whenever the insured member happens to claim refund or to seek prior authorisation of expenditure."

    Reference(s)

    Organization rules reference: Article 2(2) of Rule no. 10 of the Staff Regulations

    Keywords:

    burden of proof; dependant; dependent child; evidence; health insurance; illness; insurance; medical expenses; organisation's duties;



  • Judgment 1148


    72nd Session, 1992
    European Organisation for the Safety of Air Navigation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    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:

    discretion; freedom to choose practitioner; health insurance; medical expenses;

    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:

    discretion; domestic law; freedom to choose practitioner; health insurance; insurance benefits; medical expenses;

    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:

    administrative instruction; discretion; general decision; health insurance; individual decision; medical expenses;

    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
    ILOAT Judgment(s): 1088

    Keywords:

    definition; discretion; health insurance; insurance; limits; medical consultant; medical expenses; refund; refusal;

    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:

    confirmatory decision; decision; health insurance; medical expenses; refund; start of time limit; time limit;



  • Judgment 1139


    72nd Session, 1992
    World Health Organization
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Considerations 6-7

    Extract:

    The complainant was to undergo a course of sea-water therapy following an accident recognised as attributable to the performance of official duties. Although she had been told of the amount she was to get in compensation for her expenses, she spent considerably more. "It was not reasonable of her to assume that the expenses of a stay in a luxury hotel would be repaid when all indications [...] were to the contrary." There being other hotels to choose from, "it was not essential to the success of the treatment that the complainant should stay at the most luxurious".

    Keywords:

    cure; health insurance; medical expenses; refund;



  • Judgment 1110


    71st Session, 1991
    European Southern Observatory
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Summary

    Extract:

    In Judgment 996 the Tribunal set aside the decision to dismiss the complainant and ordered his reinstatement "with full arrears of salary and allowances". In execution of that judgment the ESO reinstated him as a member of its health insurance scheme as from the date of dismissal and deducted the corresponding premiums from his pay. The complainant's objections to the deductions are mistaken. The intention of Judgment 996 was, as far as possible, to put the complainant in the same position as if he had not been dismissed. The Tribunal is satisfied that in respect of health insurance the organisation has complied with the letter and the spirit of the judgment.

    Reference(s)

    ILOAT Judgment(s): 996

    Keywords:

    application for interpretation; consequence; contributions; deduction; health insurance; insurance; interpretation; judgment of the tribunal; medical expenses; payment; reinstatement; salary;



  • Judgment 1101


    71st Session, 1991
    European Organisation for the Safety of Air Navigation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Consideration 7

    Extract:

    The complainants, who are employees of Eurocontrol, seek the quashing of an Office Notice insofar as it informs staff that expenses arising from trace-element therapy (oligo-elements), aromatherapy and phytotherapy are not to be refunded. The Agency pleas that the complaint is irreceivable. "It is worth pointing out that in Judgment 961 [...] of 27 June 1989 the Tribunal held that it was 'competent only to entertain individual and actual disputes' and would not make prior rulings of general purport. Again in Judgment 1081 [...] of 29 January 1991 it affirmed that no appeal would lie against a general decision provided that it was such as needed in all cases to be followed by a challengeable individual one."

    Reference(s)

    ILOAT Judgment(s): 961, 1081

    Keywords:

    administrative instruction; cause of action; competence of tribunal; general decision; health insurance; individual decision; medical expenses; receivability of the complaint; refund; refusal;

    Consideration 9

    Extract:

    The complainants are challenging an Office Notice that merely informs them that expenses incurred for certain forms of treatment will not be refunded. "There will be a decision challengeable under Article VII of the Tribunal's Statute only when Eurocontrol has, in accordance with its rules, refused a staff member refund of the cost of a particular sort of treatment. The Tribunal will then rule according to the criteria it stated in Judgment 1088 of 29 January 1991, taking medical advice if need be. It may not make a prior ruling of general application to the sorts of treatment covered by the Office Notice."

    Reference(s)

    ILOAT reference: ARTICLE VII OF THE STATUTE
    ILOAT Judgment(s): 1088

    Keywords:

    administrative instruction; competence of tribunal; general decision; health insurance; individual decision; medical expenses; receivability of the complaint; refund;



  • Judgment 1095


    70th Session, 1991
    European Organisation for the Safety of Air Navigation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Summary

    Extract:

    The complainant's fees for difficult confinement were refunded at the 100 per cent rate up to a maximum limit reckoned by likening the treatment she received to a surgical operation. Though the Tribunal finds nothing wrong with setting maximum limits in general it holds that there was no valid limit at the material time on costs incurred for difficult confinements and that the complainant was entitled to the refund of her confinement expenses in full.

    Keywords:

    amount; analogy; flaw; health insurance; maximum limit; medical expenses; no provision; rate; reckoning; refund;



  • Judgment 1094


    70th Session, 1991
    European Organisation for the Safety of Air Navigation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Consideration 33

    Extract:

    The complainants object to statements of refund for confinement fees. In view of "the lack of consistency and clarity found in the reckonings, the challenged decisions must be set aside. The cases are sent back so that Eurocontrol may take new decisions according to the principles set out above and in such a way as to permit the complainants to check them."

    Keywords:

    case sent back to organisation; decision quashed; flaw; health insurance; medical expenses; refund;

    Considerations 24-25

    Extract:

    Under Article 72 of the Staff Regulations governing officials and of the General Conditions of employment of the Agency the Director general is "empowered to do whatever is needed to make the [health] scheme workable and financially sound, provided that he abides by the provisions of the Staff Regulations, and the cost is shared between organisation and staff in line with the principle of solidarity. That is why it is a proper precaution to set maximum limits on the costs of some forms of treatment and to require prior permission in some cases." Setting the rate of refund at 100 per cent for certain forms of treatment, including confinement, does not bar maximum limits.

    Reference(s)

    Organization rules reference: ARTICLE 72 OF EUROCONTROL STAFF REGULATIONS

    Keywords:

    health insurance; illness; insurance; maximum limit; medical expenses; refund; social solidarity;



  • Judgment 1088


    70th Session, 1991
    European Organisation for the Safety of Air Navigation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Summary

    Extract:

    At issue is the organisation's refusal to refund the costs of Serocytol, a pharmaceutical product which Eurocontrol regards as of no curative effect. The organisation did not go beyond the bounds of the discretion it has in the matter under Article 24(2) of Rule no. 10 concerning health and accident insurance.

    Reference(s)

    Organization rules reference: ARTICLE 24(2) OF RULE NO. 10

    Keywords:

    discretion; health insurance; medical expenses; refund; refusal;



  • Judgment 1070


    70th Session, 1991
    International Telecommunication Union
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Consideration 7, Summary

    Extract:

    The complainant submitted a claim for medical expenses incurred by his former wife which another insurance scheme had already met. He submits that he bore no responsibility for the error and acted in good faith. The Tribunal holds that as he knew that his former wife was covered under another health scheme he should have made sure that it had not previously refunded her expenses. The complainant's "conduct argues, to say the least, a degree of laxity quite inadmissible in an international civil servant in that he wilfully ran a substantial and unreasonable risk, the foreseeable outcome being the defrauding of the fund. He has only himself to blame for the consequences of his own oversight."

    Keywords:

    complainant; fitness for international civil service; good faith; health insurance; insurance; medical expenses; misrepresentation; negligence; request by a party; serious misconduct; staff member's duties;

    Consideration 7, Summary

    Extract:

    Under Article 2.7(1) of the ILO/ITU Staff Health Insurance Fund Regulations claimants must supply a statement, together with supporting documents, listing any benefits received or to be received from another health scheme in respect of each claim made. The complainant submitted a claim for his ex-wife's medical bills, which had already been reimbursed by another health scheme. "In filing such a statement the complainant had a duty to make sure that the 'supporting documents' were genuine and he could not shirk it by shifting responsibility to his former wife and professing his own ignorance and good faith."

    Reference(s)

    Organization rules reference: ARTICLE 2.7(1) OF THE ILO/ITU STAFF HEALTH INSURANCE FUND REGULATIONS

    Keywords:

    accumulation; dependant; good faith; health insurance; insurance; liability; medical expenses; misrepresentation; request by a party;

    Consideration 7

    Extract:

    The complainant was dismissed for having got the ILO/ITU Health Fund to reimburse medical costs incurred by his former wife when another health scheme had already met them. "It is irrelevant to his plea of good faith that he has instigated criminal proceedings against her in the French courts on the grounds of fraud, though he might cite her conviction, if she were found guilty of the charges, as a new fact warranting review."

    Keywords:

    dependant; evidence; good faith; health insurance; judgment of the tribunal; medical expenses; misconduct; municipal court; request by a party; termination of employment;



  • Judgment 992


    68th Session, 1990
    European Organisation for the Safety of Air Navigation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Summary

    Extract:

    The complainant's application for permission to take a cure prescribed by his doctor was rejected. The Agency's medical officer reported to the health fund that the doctor had given no clear evidence of the need for the prescribed treatment. In keeping with Article 20 of Rule No. 10 concerning sickness and accident insurance, expenses relating to a cure shall be refunded provided that the cure "is recognised as strictly necessary by the medical officer". The Tribunal sees nothing improper in the medical officer's assessment nor in the administration's ensuing denial of permission.

    Keywords:

    cure; health insurance; medical consultant; medical expenses; medical opinion; refund; refusal;



  • Judgment 944


    65th Session, 1988
    European Patent Organisation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Consideration 4

    Extract:

    The complainant and her husband are both officials of the EPO. There are no rules concerning the refund of medical expenses which cover such contingencies. The Tribunal holds that "no other provision of the Service Regulations may be applied, even by analogy, if intended to fit an essentially different set of circumstances."

    Keywords:

    analogy; applicable law; enforcement; health insurance; marital status; medical expenses; no provision; other; provision; staff regulations and rules;

    Consideration 7

    Extract:

    The complainant and her husband are employees of the EPO. In view of the fact that between them they pay a double premium, she is seeking the refund at 100 per cent of their medical expenses, and not 80 per cent as stipulated in the insurance policy. In keeping with the organisation's view, the Tribunal holds that under the material rules of the organisation, "each staff member pays contributions that depend on the amount of salary, yet is entitled to the same benefits, whatever the degree of individual risk or family situation may be. Status as an official will always prevail over status as the member of an official's family, and the right to refund derives solely from the former, not from any marital connection there may be with another official."

    Keywords:

    consequence; contributions; family relationship; health insurance; medical expenses; official; rate; refund; right;



  • Judgment 941


    65th Session, 1988
    European Organisation for the Safety of Air Navigation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Consideration 9

    Extract:

    "As the texts stand vaccinations are not ordinarily covered by the [sickness insurance] scheme [...] that the policy of other European organisations is more liberal is an example Eurocontrol may wish but is not bound to follow."

    Keywords:

    applicable law; health insurance; insurance; law of european communities; medical expenses; rule of another organisation;



  • Judgment 925


    65th Session, 1988
    European Organisation for the Safety of Air Navigation
    Extracts: EN, FR
    Full Judgment Text: EN, FR

    Consideration 11

    Extract:

    "The scheme member has a duty to support a claim with documents that are clear enough for the administration to be able to tell what the treatment was and to apply the right rate of refund."

    Keywords:

    burden of proof; disclosure of evidence; evidence; health insurance; illness; insurance; medical expenses; rate; request by a party;

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