JUDGMENT OF THE EUROPEAN UNION CIVIL SERVICE TRIBUNAL

(First Chamber)

28 April 2016

Case F‑76/15

FY

v

Council of the European Union

(Civil service — Social security — Joint Sickness Insurance Scheme — Reimbursement of medical expenses — Reimbursement rate — Recognition of a serious illness — Criteria — Article 72 of the Staff Regulations and General Implementing Provisions for the reimbursement of medical expenses)

Application:      under Article 270 TFEU, applicable to the EAEC Treaty pursuant to Article 106a thereof, in which FY seeks annulment of the decision of 8 April 2014 of the Brussels (Belgium) Settlements Office for the Joint Sickness Insurance Scheme rejecting his application for extension of the recognition of the illness suffered by his son as a serious illness and for the medical expenses connected therewith to be reimbursed at 100%.

Held:      The decision of 8 April 2014 of the Brussels (Belgium) Settlements Office for the Joint Sickness Insurance Scheme rejecting the application for extension of the recognition, as a serious illness, of the illness suffered by FY’s son is annulled. The Council of the European Union is to bear its own costs and is ordered to pay the costs incurred by FY.

Summary

Officials — Social security — Sickness insurance — Serious illness — Determination — Criteria — Obligation to examine the state of health of the person concerned — Specific, thorough examination — Judicial review — Scope — Limits

(Staff Regulations, Art. 72)

It is for the Civil Service Tribunal, as part of the limited judicial review it is called upon to perform in medical matters, to consider whether, in refusing to classify an illness as serious, the competent authority has actually taken into account the criteria which determine such a classification, and has not committed a manifest error in inferring from the medical findings communicated to it, on which the Tribunal may not adjudicate unless the administration has misinterpreted their significance, that those criteria were not all met.

As regards the Commission’s General Implementing Provisions for the reimbursement of medical expenses, Title III of which lays down the procedures for, among other things, recognition of the status of serious illness, although the four criteria set out in point 1 of Chapter 5 of Title III are cumulative in nature, in the examination carried out by the medical officer or the medical council, the assessment made of any one of the criteria is — in view of the interdependence which the provisions establish between the four criteria — likely to affect the assessment made of the other criteria. Thus, although one of the criteria may appear not to be satisfied when considered in isolation, examination of it in the light of the assessment made of the other criteria may lead to the opposite conclusion, namely that that criterion is in fact satisfied, such that the medical officer or the medical council is precluded from undertaking consideration of merely one criterion taken on its own.

In that regard, it is for the Tribunal, in the context of the limited review it may exercise over opinions issued by the medical bodies intervening during the course of the procedure for recognising the existence of a serious illness, to ensure that those opinions were adopted on the basis of a specific examination of the actual state of health of the person concerned, an examination which is appropriate to the circumstances of the case and which takes into account in a comprehensive manner, as required by point 1 of Chapter 5 of Title III of the General Implementing Provisions, the four interdependent criteria set out in that point.

(see paras 30, 31, 33)

See:

Judgments of 18 September 2007 in Botos v Commission, F‑10/07, EU:F:2007:161, para. 41, and 28 September 2011 in Allen v Commission, F‑23/10, EU:F:2011:162, paras 66, 79 and 80