Background to the complaint

1. The complainant is the spouse of an EU staff member. He and his child have primary coverage under the national health insurance scheme in an EU Member State. As members of the staff member’s family, they also benefit from a complementary (‘top-up’) coverage under the EU Joint Sickness Insurance Scheme (JSIS), the sickness insurance scheme for EU staff members, pensioners and dependants. JSIS is managed by the European Commission’s Office for the Administration and Payment of Individual Entitlements (Paymaster Office, hereinafter: ‘PMO’).

2. In April 2022, the staff member informed the PMO that, in September 2022, she would take up a position in an EU Delegation in a non EU-country, where her spouse and child would accompany her. She stated that, while her two family members had primary health coverage under the national scheme, this scheme would not cover them in the country to which she was posted. The staff member asked the PMO whether it could grant them primary coverage (for illness and accidents) in that country under the JSIS.  

3. The PMO replied to the staff member that it could not grant her family members primary coverage, as her spouse continued to be employed in an EU Member State and, thus, also to be covered under the national scheme. Nevertheless, since the national scheme would not cover her two family members in the country to which she was posted, the PMO would reimburse their medical expenses during their stay there under the JSIS primary coverage rules.

4. In July 2022, the staff member asked the PMO to issue certificates about the primary coverage of her spouse and child in the country to which she was posted. She resent her request in August 2022, noting that the certificates that the PMO had in the meantime issued concerned only the ’top-up’ coverage and, therefore, could not be used to prove primary coverage in the country to which she was posted. She added, in particular, that her child had to undergo compulsory health screening in that country to be able to enrol in a school. As such, she needed to prove her child’s primary coverage by JSIS.

5. The PMO issued the requested certificate for the staff member’s child, but not for her spouse, as there were some supporting documents missing. It stated that it would issue the same certificate for her spouse once it received the missing documents.

6. The staff member submitted the missing documents and flagged to the PMO that she needed to have her spouse’s certificate ready before she moved (end-August 2022) and that she would not have access to her computer during the last week of August 2022.

7. The PMO replied to the staff member that the certificate she had requested for her spouse was not standard and, as such, was not generated automatically; rather, it had to be issued manually. Consequently, it would issue such a certificate only for a specific reason, that is, if a healthcare provider in the country in question were to specifically request proof of primary coverage for her spouse.

8. In September 2022, the complainant wrote to the PMO to complain about how it had dealt with the request for the health insurance certificate. The complainant also complained to the Commission’s Secretary-General (‘Secretary-General’). He contended that, although the PMO had confirmed his primary coverage in the country to which his wife was posted and had initially promised to issue a certificate for him (as it had done for his child), it then refused to do so. He contended that he needed to have such certificate in advance, in case of a medical emergency.

9. Dissatisfied with how the Commission had dealt with the matter, the complainant turned to the Ombudsman in September 2022. He contended that the PMO had not properly handled the request for a certificate proving his primary insurance coverage in the country to which his wife was posted. He was also concerned that the Secretary-General had not yet replied to his complaint.

10. In early October 2022, the PMO sent an email to the complainant in which it stated that, since the national scheme did not cover his and his child’s medical costs in the country to which his wife was posted, his wife could request reimbursement of their medical costs under the same principles as those that applied for primary coverage. However, as the JSIS certificates in use at the time could only mention the type of a beneficiary’s coverage under the JSIS (either primary or top-up), the PMO was taking a closer look at those certificates to see how they could be improved to be more easily understandable to the outside world. The PMO concluded that it would transmit the new document to the complainant’s wife once it was ready.

11. In mid-October 2022, the PMO sent another email to the complainant. It referred to his complaint to the Secretary-General and stated that the PMO had issued a JSIS top-up coverage certificate for both the complainant and his child upon receipt of the relevant documentation. What the complainant was additionally requesting was a letter tailored to his individual situation, which no other JSIS beneficiary had asked for before. The PMO emphasised that processing exceptional requests might take longer.

12. The complainant forwarded these emails to the Ombudsman, claiming that the Commission had still not provided an adequate certificate. As such, the Commission was putting him at risk in case of a medical emergency.

The inquiry

13. The Ombudsman opened an inquiry and asked the Commission to clarify how it was dealing with:

A. the complainant’s request for a health insurance certificate; and

B. the complainant’s complaint to the Secretary-General.

14.  The Ombudsman received the Commission’s reply on the complaint and, subsequently, the comments of the complainant in response to the Commission’s reply.

15. In its reply, the Commission noted that, in mid-September 2022, it had sent to the complainant a certificate similar to that issued for his child. However, in his follow-up exchange with the Ombudsman, the complainant claimed that he had only received a certificate regarding the top-up coverage and not one regarding reimbursement under the primary coverage rules.

16. The Ombudsman then asked the Commission to specify which channel the PMO had used to send the requested certificate. The Commission clarified that the relevant certificate had been sent to the complainant’s wife through the secured communication channel that the PMO uses for JSIS members. All active EU staff members have access to that channel, which is linked to their professional e-mail addresses. The Commission sent to the Ombudsman a copy of that certificate, which the Ombudsman then forwarded to the complainant.

17. The complainant commented that his wife most likely had not received the email notification that the certificate was available at the internal communication channel, because her email address had changed following her relocation to the EU Delegation in September 2022.

18. In January 2023, the complainant communicated to the Ombudsman and the Commission issues that he had faced with healthcare providers in the non-EU country when using the certificate provided. He asked for a certificate phrased in clearer terms.

19. In mid-January 2023, the Commission sent to the complainant a revised version of the certificate.

How the Commission handled the complainant’s request for a health insurance certificate

Arguments presented to the Ombudsman

20. The complainant contended that the Commission had failed to deal properly with the request for a certificate proving his primary insurance coverage in the country to which his wife was posted. He was concerned that healthcare providers in that country would refuse to provide him with urgent health care without proof of insurance coverage.

21. In its reply to the Ombudsman, the Commission stated that there are two standard JSIS certificates of health insurance coverage: the JSIS primary coverage certificate and the JSIS top-up coverage certificate. These certificates are available to all JSIS members and can be downloaded from the relevant online platform. Any other type of certificate needs to be prepared manually and is issued upon request, “in duly justified cases after an analysis of the file and the request”.

22. The Commission further noted that this was the first time it had received such a request from a staff member in the EU Delegation in question. It added that it had informed the complainant that, since he and his child were not covered in that country under their national primary health insurance scheme, JSIS would ”grant primary reimbursement for expenses incurred in the [third country] only, while the coverage [would remain] in top-up with the JSIS”.

23. The Commission also stated that, even though the addressee of the requested certificate and the specific need for it were never identified during its extensive correspondence with the complainant, the PMO prepared a certificate, similar to the one issued for the complainant’s child, and sent it in mid-September 2022.

24. The Commission further stated that the PMO had consistently responded to the complainant, providing him with clarifications in a timely manner.

The Ombudsman's assessment

25. The complainant requested the PMO to provide him with a certificate that he has, in practice, coverage equivalent to primary insurance coverage under the JSIS in the non-EU country in question, as he was concerned that healthcare providers in that country might refuse to provide urgent healthcare without such proof. The Ombudsman finds the complainant’s concerns understandable and his request reasonable.

26.  The Commission acknowledged from the beginning that the medical expenses incurred by the complainant and his child in the non-EU country would be reimbursed under the JSIS primary coverage rules. However, while the Commission issued the relevant certificate for the complainant’s child in a timely manner (for the child to enrol in school), it appeared less willing to do the same for the complainant. The Commission referred to the time it takes to issue such “non-standard” certificates and to the lack of a specific reason for issuing one for the complainant.

27. Following extensive exchanges, in which the complainant reiterated his request, the Commission issued the requested certificate in mid-September 2022. In January 2023, the Commission also provided the complainant, upon his request, with a revised, more explicit and clearer, version of the certificate. The Commission has thus settled this aspect of the complaint.

28. However, the Ombudsman finds that the Commission did not handle the complainant’s request in a fully service-minded manner.

29. The Commission gave rather contradictory information to the complainant and his wife on different occasions concerning the delays in providing the requested certificate, ranging from the absence of a specific reason for issuing the requested certificate to the longer time needed to prepare it.

30.  In addition, the Ombudsman considers that it was reasonable for the complainant to have concerns about access to healthcare in the absence of a certificate confirming that any expenses would be reimbursed under the JSIS in a manner equivalent to primary coverage. This is even more so as the country to which the complainant’s wife was posted is known for its high medical costs.[1] Against this background, the reasons referred to by the Commission for its hesitancy and delay in issuing the requested certificate are not entirely acceptable.

31. The Ombudsman understands that, given the high number of JSIS beneficiaries, the PMO has to handle a high volume of requests, and that certificates prepared manually (rather than generated automatically) may take longer to prepare. However, the text of the certificate eventually issued was short and required only slight changes compared to the standard certificate. As such, the Ombudsman considers that it took the PMO a disproportionate amount of time to process the complainant’s request. Furthermore, the PMO had already issued a certificate for the complainant’s child, which could have served as the basis for the complainant’s certificate.[2] This delay and hesitancy not only caused unnecessary stress to the complainant and his wife (the staff member), but also led to administrative burden and significant investment of resources on the side of the Commission, as it resulted in the involvement of different departments from various levels.

32. To prevent similar incidents in future, the Ombudsman encourages the Commission to take measures to ensure that it handles such requests in a timely and overall more efficient manner. For example, the PMO could put in place templates for similar certificates.

33. Part of the issues in this case are due to poor communication. In particular, while the Commission issued the requested certificate in mid-September 2022, it was only in December 2022 that the complainant became aware that it had done so (after the Ombudsman clarified the matter with the Commission). It appears this was due to a change in the email address of the complainant’s wife.[3]

34. The Ombudsman acknowledges that the Commission’s practice to communicate information containing personal data through secured communication channels only is administratively sound and reflects the relevant EU data protection rules. Given that the complainant benefits from the JSIS health insurance coverage in his capacity as family member of the EU staff member (his wife), who is the one that made the initial request on behalf of the complainant, it is also understandable why the PMO used this internal communication channel.

35. That said, it appears that the only way in which the complainant could have known that an important official document concerning him individually was available was through his wife. The Ombudsman is of the view that, as shown by the facts in this case, this way of processing a request of this nature is not ideal.

36. The Ombudsman considers that offering the complainant the possibility to be notified (in addition to his wife) that the requested certificate was available on the relevant platform would have been a better way to proceed, as he, the JSIS beneficiary individually concerned in this case, would have been directly informed. This could be done by giving the staff member the possibility to declare additional email addresses to which they would like the PMO to send a notification when a requested certificate is available (for example, the email address of the family member concerned by the certificate). To that end, the online request form of the PMO (’Staff Contact’) could include a relevant field (for the staff member to fill in if needed) along the following lines: “Additional email address(es) to which a notification should be sent when a reply is available: ... “.[4] The Ombudsman encourages the Commission to consider such an option.

37. In this case, for example, the staff member could have declared her private email address and/or the email address of her husband. So, even if, for any reason, the staff member had no (longer) access to the professional email address linked to the online platform, she and/or her husband could receive the notification regarding the requested certificate through a different email address, directly accessible to them.

How the Commission handled the complaint to the Secretary-General

Arguments presented to the Ombudsman

38. The complainant contended that he had not received a reply to his complaint to the Commission’s Secretary-General.

39. In its reply to the Ombudsman, the Commission stated that the PMO had replied to the complainant’s complaint in mid-October 2022, following instructions by the Secretary-General.

The Ombudsman's assessment

40. It is clear from the Commission’s reply to the Ombudsman that the email it sent to the complainant in mid-October 2022 was the Commission’s formal reply to the complainant’s complaint to its Secretary-General. This reply was sent within the relevant time limit, and before the Ombudsman opened the inquiry. There was thus no maladministration in how the Commission handled the complaint to the Secretary-General.

Conclusion

Based on the inquiry, the Ombudsman closes this case with the following conclusions:[5]

The European Commission has settled the issue regarding the complainant’s request for a certificate proving coverage under the Joint Sickness Insurance Scheme (JSIS).  

There was no maladministration in how the European Commission handled the complainant’s complaint to the Commission’s Secretary-General.

The complainant and the Commission will be informed of this decision.

 

Rosita Hickey
Director of Inquiries

Strasbourg, 15/11/2023

 

[1] On the Commission’s intranet, on the page dedicated to “direct billing” from JSIS in case of high medical expenses, the country is listed as an example among those with “expensive medicine”.

[2] In fact, the only difference between the certificate that the PMO issued for the complainant’s child and the one issued for him was the names of the beneficiaries.

[3] In the correspondence with the PMO (through the internal communication channel), the staff member’s professional email address appeared as [...]@ec.europa.eu (which is a Commission email address), whereas her current professional email address is [...]@eeas.europa.eu (that is, an email address of the European External Action Service).

[4] The Ombudsman considers that such an option would not raise any particular data protection issues, as the PMO and JSIS notifications are ’no-reply’ emails with a very generic content, simply informing the recipient that a message/reply is available on the relevant platform (to which, of course, only staff members can have access). In particular, currently, automatic notifications generated by the PMO’s on line platform  (“Staff Contact”) read as follows: “A new message is available in your Staff Contact. To consult it, please log in using your username and password when you click on the following link [...]”. Depending on the case, JSIS on line notifications read as follows: “A new document is available on your JSIS-Online. In order to consult it, please login using your credentials to https:// [...]”  or “The certificate you requested is available in your JSIS-Online. In order to download it, please login using your credentials to https://[...]”.

[5] This complaint has been dealt with under delegated case-handling, in accordance with the Decision of the European Ombudsman adopting Implementing Provisions.