JUDGMENT OF THE COURT OF FIRST INSTANCE (Third Chamber)

7 November 2002

Case T-199/01

G

v

Commission of the European Communities

‛Officials — Social security — Refusal to reimburse medical expenses — Inefficacious treatment’

Full text in French II-1085

Application for:

annulment of the implied rejection of the complaint submitted by the applicant against the decision of the office responsible for settling claims of 30 November 2000 refusing reimbursement of expenses relating to magistral preparations prescribed by the doctor providing treatment.

Held:

The application is dismissed. The parties are ordered to bear their own costs.

Summary

The right to claim protection of legitimate expectations presupposes that three conditions are satisfied. First, specific, unconditional and consistent assurances originating from authorised and reliable sources must have been given to the person concerned by the Community administration. Second, those assurances must be such as to lead the person to whom they are addressed to entertain a legitimate expectation. Third, the assurances given must comply with the relevant rules. (see para. 38) See: T-203/97 Forvass v Commission [1999] ECRSC I-A-129 and II-705, para. 70. and the case-law cited

Even if the approval of claims for reimbursement of medical expenses submitted in the past by a member of the Joint Sickness Insurance Scheme of the Community institutions (JSIS) constitutes a specific assurance as to the existence of a right to future reimbursement for identical treatments, it is obvious that, being contrary to the relevant regulations, those assurances cannot give rise to a legitimate expectation. For the purpose of safeguarding the financial equilibrium of the JSIS, the institutions have provided, in the first paragraph of section XV(3) of Annex I to the Rules on Sickness Insurance for Officials of the Communities, for the possibility of refusing reimbursement of expenses relating to treatments regarded as inefficacious or unnecessary. The fact that such a possibility is expressly provided for in the rules - which every official knows or is deemed to know - is sufficient in itself to preclude a person covered by the JSIS from relying on the existence, with respect to himself, of a legitimate expectation as to the automatic reimbursement of his medical expenses. Even though a member may reasonably take the view that his medical expenses will generally be reimbursed within the limits laid down in Article 72(1) of the Staff Regulations, he must nevertheless be aware of the fact that reimbursement may be refused by the office responsible for settling claims if, after consulting the medical officer, it considers that those expenses relate to an inefficacious or unnecessary treatment. Similarly, subsequent developments in scientific knowledge may establish that the medicinal preparation for which he has obtained reimbursement in the past is not efficacious in treating the pathology from which he suffers or that the medicinal preparation in question is efficacious only for a particular aspect of that pathology and/or under strict conditions. (see paras 41-42) See: T-12/94 Daffix v Commission [1997] ECRSC I-A-453 and II-1197, para. 116

The appointing authority must, for every claim for reimbursement submitted by a member of the Joint Sickness Insurance Scheme, determine whether the conditions for reimbursement laid down in Article 72(1) of the Staff Regulations are satisfied by reference to the matters of fact and of law disclosed by the person concerned, without being bound by a previous decision adopted on the basis of different or less complete evidence. (see para. 43) See: T-33/89 and T-74/89 Blackman v Parliament [1993] ECR II-249, para. 82