Dear X,
On 8 October 1998, you made a complaint to the European Ombudsman against the European Parliament concerning its refusal to reimburse fully the medical expenses caused by your spouse's illness.
On 14 December 1998, I forwarded the complaint to the President of the European Parliament. The Parliament sent its opinion on 10 May 1999 and I forwarded the opinion to you with an invitation to make observations, if you so wished. On 14 October 1999, I received your observations on the opinion of the Parliament. On 30 July 1999, I forwarded the complaint to the President of the European Commission. On 13 October 1999, the Commission sent its opinion, which I forwarded to you. On 14 December 1999, I received your observation on the opinion of the Commission.
I am writing now to let you know the results of the inquiries that have been made.

THE COMPLAINT

According to the complainant, the relevant facts were as follows:
The complainant is a civil servant of the Parliament. In 1997 the complainant's spouse fell ill. The illness was classified as a life-threatening condition and it was covered by the Joint Sickness Insurance Scheme of the European Communities (hereafter Sickness Insurance Scheme) at 100%. The extraction of 12 teeth was also covered at 100%.
The complainant stated that once his spouse was removed from hospital, the condition was no longer described as medical but as dental as far as the Sickness Insurance Scheme was concerned. Although the extraction of the teeth in hospital was covered at 100%, the replacement of those teeth was then subject to a different financial regime. The complainant had asked the Comité de Gestion Assurance Maladie (hereinafter CGAM) to reimburse fully three crowns and to double the ceiling for another three crowns. The CGAM refused the claim on the grounds that the existing rules do not provide for exceptions to be made to the reimbursement ceiling for fixed dental prostheses.
Furthermore, the complainant stated that the maximum ceiling for the replacement of teeth has been changed from year to year on the basis of accountancy considerations with no possibility of clinical flexibility. The complainant considered this practice to be arbitrary and inconsistent since the dental reconstruction was a contiguous and inextricable part and consequence of his spouse's medical condition.
The complainant submitted his case to the Secretary General of the Parliament and to the CGAM according to Article 90(1) and (2) of the Staff Regulations. His claim was refused by the CGAM.
The complainant thereafter lodged a complaint with the Ombudsman, alleging that the decision not to reimburse fully his spouse's dental expenses was arbitrary and inconsistent.

THE INQUIRY

The Parliament's opinion
In its opinion, the Parliament referred to the rate applied by the Sickness Insurance Scheme for the reimbursement of medical expenses. It stated that maximum rates are laid down for the reimbursement of the cost of treatments of this kind. The Parliament stated that these rates cannot be exceeded even if the underlying illness is regarded as a serious illness and costs arising from this illness would normally by eligible for reimbursement at 100% pursuant to Article 72 (1) of the Staff Regulations.
The maximum limit is laid down by the Rules on sickness insurance for officials of the European Communities (hereafter: the Rules on sickness insurance) and in particular, in the second and third subparagraph of paragraph 1 of the Annex 1 Section IV (Special Cases), Annex III (B)(1) (fixed prostheses) and (2) (removable prostheses).
The complainant's observations
The complainant accepted that the Parliament had followed the existing rules as laid down by the Management Committee of the Common Sickness Insurance Scheme.
The complainant also made remarks concerning the manner in which Parliament officials had dealt with his case. The European Ombudsman has not understand these remarks as a new allegation which the complainant wished the Ombudsman to investigate.
The complainant further stated that his complaint was mainly about the managerial decision taken by CGAM and by the Luxembourg Settlement Office in relation to the fact that the consequences of his spouse's illness were subject to a completely different reimbursement regime that the original illness itself. The complainant insisted that exceptions to the rules should be made in exceptional cases, such as unavoidable heavy expenses.

FURTHER INQUIRIES

Given that the Luxembourg settlement office for medical expenses is under the administrative umbrella of the Commission, the Ombudsman asked the Commission for its opinion on the matter.
The Commission's opinion
The Commission confirmed that the illness of the complainant's spouse was recognised as a serious illness according to Article 72 paragraph 1 of the Staff Regulations.
As regards the reimbursement procedure, the Commission stated that costs for the preparation of three teeth, during the stay in hospital, were reimbursed at 100% of the framework of hospital costs arising from serious illness. For the continuation of the treatment, the complainant received a first authorisation for dental treatment in which it was not taken into account that the dental costs were relating to a serious illness and therefore were eligible for a reimbursement under the conditions specified under Annex 1, Section IV of the Rules on Sickness Insurance for officials. This was rectified and a new authorisation was sent in which in accordance with the second and third subparagraphs of paragraph 1, Annex 1 Section IV, the reimbursement was limited to the maximum amount specified for fixed prostheses.
As regards the legal basis, the Commission stated that the Rules on sickness insurance do not provide for any exception to be made to these limits. Given that the Settlement Office has to apply the Rules, it could not have taken the decision to reimburse any other amount in this particular case.
As regards the variations in the ceiling, the Commission stated that the maximum reimbursable amounts have been in application since the change of the Rules in January 1991. As in any sickness insurance scheme, the Rules, including the ceilings, are updated on a regular basis. The amount spent by the Scheme has to balance against the incoming contributions from the members and the Institutions. The changes to the Scheme brought in 1991 also comprised a reduction in expenditure in the dentistry sector. This reduction is applicable nevertheless to all members of the Scheme.
The complainant's observations
The complainant maintained his complaint.
He re-iterated that the CGAM should have provided for an exception to be made to the limits of reimbursement, in particular for severe illnesses and resulting dental consequences in order to ensure that the burden of any deficit was borne equally by all members of the Sickness Insurance Scheme.
The complainant further stated that according to the CGAM Information brochure published in Autumn 1999 several changes were introduced, including special reimbursements.

THE DECISION

1 Reimbursement by the Sickness Insurance Scheme
1.1 The complainant alleged that the decision not to reimburse fully the dental expenses for his spouse was arbitrary and inconsistent.
1.2 The Parliament stated that the medical expenses of the complainant's spouse were reimbursed in accordance with the rules. It referred to the rates applied by the Sickness Insurance Scheme for the reimbursement of medical expenses pursuant to which maximum rates are laid down for the reimbursement of the cost of treatments of this kind. The Parliament stated that these rates cannot be exceeded even if the underlying illness is regarded as a serious illness.
1.3 The Commission confirmed that the illness of the complainant's spouse was recognised as a serious illness according to Article 72 paragraph 1 of the Staff Regulations. As regards the reimbursement procedure for the time after the complainant's spouse was removed from hospital, the Commission stated that the complainant received the authorisation for dental treatment according to the conditions specified under Annex 1, Section IV of the Rules on Sickness Insurance for officials. Pursuant to the second and third subparagraphs of paragraph 1, Annex 1 Section IV, the reimbursement was limited to the maximum amount specified for fixed prostheses. The Commission further stated that the Rules on sickness insurance do not provide for any exception to be made to these limits.
1.4 The inquiry into this case therefore showed that the decision taken was in accordance with the applicable rules.
1.5 In his observations, the complainant accepted that the existing rules had been applied, but argued that the rules should provide for exceptions. The Ombudsman has not dealt with this new claim, because it appears to concern the merits of existing legislation and therefore does not raise an issue of possible maladministration.
1.6 In his observations, the complainant also stated that according to the CGAM Information brochure published in Autumn 1999 several changes were introduced, including special reimbursements. Given that the changes mentioned by the complainant appear to have been introduced after the complainant's claim had been made and dealt with, the Ombudsman does not consider it justified to conduct further inquiries on this point.
2 Conclusion
On the basis of the European Ombudsman's inquiries into this complaint, there appears to have been no maladministration by the European Parliament. The Ombudsman therefore closes the case.
The President of the European Parliament and the President of the European Commission will also be informed of this decision.
Yours sincerely,
Jacob SÖDERMAN