Background to the complaint

1. The complainant is a retired staff member of the Commission, who lives in Brazil. Both the complainant and his wife are covered by the Joint Sickness Insurance Scheme of the European institutions (JSIS)[1]. In 2014, the complainant had a serious accident. He was hospitalised and needed subsequent medical care. In 2015, the complainant’s wife also had a serious accident and needed long-term medical care.

2. For both incidents, the complainant made a request to the JSIS for direct billing[2] to cover the incurred medical costs. The request was granted. Subsequently, the Commission’s Paymaster Office (PMO)[3] determined that the complainant was responsible for EUR 38 505.28 of the costs it had covered up-front, which he would have to repay.

3. In 2015, in accordance with the applicable rules[4], the PMO sought to deduct a fixed amount from the complainant’s monthly pension to cover the complainant’s outstanding debt to the JSIS. The PMO also informed the complainant that he was entitled to benefit from a ‘special reimbursement facility’[5] that could significantly reduce the debt.

4. Between 2015 and 2017, there was significant correspondence between the complainant and the PMO. In 2017, he made an administrative complaint to contest the recovery of the medical expenses and how his file had been dealt with. The complaint was rejected. However, the Commission again informed the complainant that he could benefit from the special reimbursement facility.

5. The complainant turned to the Ombudsman. He took issue with the fact that the PMO had sent applicable forms for the special reimbursement facitity in French, a language he does not master. He also argued that he had not seen the original hospitals bills (which JSIS had paid directly), and was thus not in a position to assess the accuracy of the bills. As such, he could not accept the Commission’s decision to recover an amount that he could not verify. Finally, the complainant took the view that the PMO had made inappropriate statements implying he and his wife had engaged in fraudulent activities.

The inquiry

6. The Ombudsman opened an inquiry into how the Commission handled the reimbursement procedure and the statements made by the PMO. 

7. In the course of the inquiry, the Ombudsman received the reply of the Commission and the comments of the complainant in response to that reply.

8. In its reply, the Commission expressed regret with how the complainant and his wife had perceived the statement by the PMO, and stated that it had not intended to imply fraudulent activities by them.

9. The Commission subsequently provided the Ombudsman with the relevant forms to enable the complainant to benefit from the special reimbursement facility, as well as information on the procedure to follow. The Ombudsman then advised the complainant and his wife on how to proceed.

10. The Commission swiftly processed the complainant’s application. It cancelled the outstanding debt and stopped the monthly deduction from the complainant’s pension.  

The Ombudsman's assessment

11. The Ombudsman’s inquiry focused on assisting the complainant to benefit from the special reimbursement facility. This facility has now been applied. The Commission responded positively to the Ombudsman’s intervention on behalf of the complainants, and resolved the other issues raised by the complainant.

Conclusion

Based on the inquiry, the Ombudsman closes this case with the following conclusion[6]:

The European Commission has settled the issues raised in this complaint.

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

 

Marta Hirsch-Ziembińska

Head of Inquiries and ICT - Unit 1

Strasbourg, 11/12/2018

 

[1] JSIS is the sickness insurance scheme for the employees of the European Union. More information is available here: http://ec.europa.eu/pmo/info.sickinsurance_en.htm.

[2] Under the direct billing facility, JSIS makes advanced payments to cover the up-front medical costs incurred by members of the scheme. JSIS subsequently calculates the amount of the medical expenses for which it is responsible and the amount to be covered by the insured person.

[3] The PMO administers, calculates and pays the financial entitlements of the staff of the European

Commission.

[4] Title III, Chapter 4, Point 1 of the general implementing provisions for the reimbursement of medical expenses:

“The costs to be met by the member are, as a rule, deducted from later reimbursements, or from the salary, pension or other sums owing from the institution. At the request of the Settlements Office, the balance may be reimbursed by a transfer to the JSIS bank account.”

http://ec.europa.eu/pmo/tender/06_annexe6_dge_en.pdf

[5] In accordance with Article 72(3) of Regulation No 31 (EEC), 11 (EAEC), laying down the Staff Regulations of Officials and the Conditions of Employment of Other Servants of the European Economic Community and the European Atomic Energy Community (the Staff Regulations).

[6] This complaint has been dealt with under delegated case handling, in accordance with Article 11 of the Decision of the European Ombudsman adopting Implementing Provisions