62019TJ0736_RES
Case T‑736/19
HA
v
European Commission
Judgment of the General Court (Fourth Chamber), 16 December 2020
(Civil service – Officials – Reimbursement of medical expenses – Reimbursement ceiling for sleep apnoea devices – Action for annulment – Measure not merely confirmatory – Sufficient interest to institute proceedings – Admissibility – Joint rules on sickness insurance for officials – General implementing provisions)
Officials – Social security – Sickness insurance – Sickness expenses – Reimbursement – Reimbursement ceilings – Set in the general implementing provisions – Whether permissible – Interpretation of those provisions as impliedly setting a reimbursement ceiling where such a ceiling is not expressly set in the text – Not included
(Staff Regulations, Art. 72(1); Rules on Sickness Insurance, Art. 20)
(see paragraphs 66, 68, 69, 83, 85, 89)
Résumé
The applicant, HA, a former official of the Commission, is covered under the joint sickness insurance scheme of the European Communities (JSIS). Since 2012, she has used a continuous positive airway pressure device designed to alleviate sleep apnoea (a ‘CPAP device’). She obtained a series of prior authorisations from the settlements office which were necessary in order to obtain reimbursement of the costs of hiring the CPAP device.
When, in February 2014, the applicant made a new request, the settlements office issued a prior authorisation for the purchase of a CPAP device as it considered that only a purchase, rather than a continued hire, could be medically justified. However, the applicant made a claim for the reimbursement of the costs she had incurred in hiring her CPAP device since 1 March 2014.
The settlements office subsequently issued authorisation to the applicant for the hire of a CPAP device for a five-year period and set a reimbursement ceiling corresponding to that provided in the general implementing provisions (
1
) for the purchase of a CPAP device. An increase corresponding to the reimbursement of the costs of maintenance and purchase of accessories was also applied.
Finally, by the decision of 17 January 2019, adopted in response to the request for an extension to the prior authorisation for the hire of her CPAP device, the settlements office extended that authorisation for five years and again set the same reimbursement ceiling. The applicant disputed that decision, claiming, inter alia, that it had been adopted in breach of the applicable rules which did not provide for any reimbursement ceiling on the hire of a CPAP device.
By its judgment, the Court annuls the decision of the settlements office and clarifies the condition on which reimbursement ceilings for medical expenses for JSIS members are applied.
Findings of the Court
The Court points out that the possibility of the general implementing provisions not setting reimbursement ceilings is expressly envisaged in the Joint Rules, (
2
) which even provide for a specific procedure in such a situation in order to protect the financial equilibrium of the JSIS. As a result, since the Commission is the competent authority for the purposes of adopting the general implementing provisions, if the Commission intends to set a reimbursement ceiling on a particular treatment, it is for that institution to ensure that there is express mention of that ceiling in those provisions.
Consequently, in a situation where there is no ceiling expressly mentioned in the general implementing provisions for a particular treatment, the general implementing provisions cannot be interpreted as impliedly setting such a ceiling. In that regard, following an examination of the wording of the applicable provisions, the Court concludes that the general implementing provisions do not provide for any reimbursement ceiling on the hire of a CPAP device. In addition, according to the Court, the fact that the general implementing provisions include a reimbursement ceiling in relation to the hire of another piece of medical equipment but not in relation to the hire of a CPAP device confirms that no ceiling has been set on the hire of the latter, even impliedly.
The Court notes that that conclusion cannot be called into question by the Commission’s arguments that it is implied under the general implementing provisions that, in a case of long-term use of a CPAP device, the purchase of a device is necessary for medical reasons as well as budgetary reasons.
The Court states, in that regard, that such an interpretation of the general implementing provisions does not follow from the wording of those provisions, which do not set any time limit on the hire of CPAP devices and do not require such devices to be purchased. Furthermore, the fact, even if established as such, that it may be necessary on medical grounds to purchase a CPAP device, rather than to hire one, does not justify the failure to make any mention of that in the general implementing provisions.
Lastly, the Court notes that the fact that the hire of a CPAP device for more than three months is conditional, as is the purchase of such a device, on prior authorisation does not mean that the reimbursement ceiling provided for in the general implementing provisions on the purchase of such a device also applies to a long-term hire of the device.
(
1
)	Commission Decision C(2007) 3195 final of 2 July 2007 laying down general implementing provisions for the reimbursement of medical expenses.
(
2
)	Joint Rules on sickness insurance for officials of the European Communities adopted on 24 November 2005 by the EU institutions pursuant to Article 72 of the Staff Regulations of Officials of the European Union.