Proposal for a common Rules on the insurance of officials of the European Communities against the risk of accident and of occupational disease
Date: 2004-04-07
Institutions: European Commission
Subjects: European official, health insurance, occupational disease, personal accident insurance













EUR-Lex - 52004SC0414 - EN






Important legal notice




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52004SC0414

Proposal for a common Rules on the insurance of officials of the European Communities against the risk of accident and of occupational disease  /* SEC/2004/0414 final */  








[pic] | COMMISSION OF THE EUROPEAN COMMUNITIES |Brussels, 7.4.2004SEC(2004) 414/2Proposal for aCOMMON RULESon the insurance of officials of the European Communities against the risk of accident and of occupational disease (presented by the Commission)EXPLANATORY MEMORANDUM1.  Modifications stemming from provisions of new Staff RegulationsA number of changes are needed on the basis of the new Staff Regulations, which will enter into force on 1 May 2004.2.  “Official” replaced by “insured party” to take account of the fact that under Articles 28 and 93 of the new Conditions of employment of other servants Article 73 will cover both temporary and contract staff.3.  Amendment of Article 5 first indent in line with the new wording of Article 40 of the Staff Regulations and Article 17 of the Conditions of employment of other servants.4.  Deletion of the first two paragraphs of Article 8 following adoption of Article 85a of the Staff Regulations.5.  Deletion of Article 9, obsolete on introduction of Article 85a of the Staff Regulations.6.  Alteration of Article 27 to make compensation payable in euros.7.  Article 30 on repeal of the present rules is added and the second paragraph of that Article makes the old rules applicable if the draft decision (Article 20(1)) is notified before the date from which the new rules are applicable. The choice of the criterion of the date of notification provided for in Article 20(1) will undoubtedly restrict the crossover period during which the old provisions remain applicable. The new rules will therefore also apply to any accident or occupational disease case where a draft decision is adopted after the date of their introduction, including cases reopened.8.  Changes necessitated by Court of Justice case lawOther changes have become necessary in the wake of Court of Justice case law in recent years.9.  The second indent of Article 4(1)(b) is deleted in line with the principle of legal certainty specified in the judgment of 20 September 2001 in Case T-171/00 Spruyt v Commission. It is impossible to determine a list of dangerous sports using objective risk criteria and this exclusion is no longer present in most accident insurance contracts. On the same grounds points (c) and (d) have also been deleted.10.  Article 20 (ex-Article 21) is divided into numbered paragraphs and now requires that the request for a Medical Committee opinion state the name of the doctor representing the insured party and be accompanied by a report from him or her to the institution's medical officer covering the points disputed. The intention is to provide a clearer description of the procedure that respects the Court's findings (cf. judgment in Case 187/95 R v Commission [1997] ECR-SC II-729) and Regulation (EC) No 45/2001 of the European Parliament and of the Council on the protection of individuals with regard to the processing of personal data by the Community institutions and bodies.11.  In Article 22 (ex-Article 23) paragraph 1 requires in order to guarantee objective, consistent and sufficiently well-supported assessment of the case that an expert on assessment and repair of physical injury be appointed as third member of the Committee. The aim here is for the assessment be made in full respect for the provisions on accident and occupational disease cover of Article 73 of the Staff Regulations and for consistency of the Medical Committee's report and its conclusions to be guaranteed, in accordance with confirmed case law (cf. judgments in Cases T-300/97 Latino v Commission [1999] ECR-SC II-1263 and T-27/98 Nardone v Commission [1999] ECR-SC II-1293).12.  Simplification and updating of cover provisionsThe purpose of the third group of changes is to simplify and modernise the cover provisions. They include the following:13.  The new wording of Article 2(1) defines more clearly what an accident is. Three requirements have to be met before payment can be made under the rules.14.  Suicide is added to the Article 2(2) cover provisions in replacement of 'involuntary suicide' covered under Article 7(2) third indent. At present Article 7 accepts suicide and attempted suicide while the balance of the mind is disturbed committed in the course of or in connection with the performance of official duties, on the way to or from work, or in the aftermath of or as a result of an accident or occupational disease covered by Article 73 of the Staff Regulations. In the absence of a precise definition, either legal or medical, of involuntary suicide and given that suicide committed in the course of or in connection with the performance of official duties or on the way to or from work does not differ from suicide committed elsewhere, suicide should be covered under Article 73 without qualification. There is a further argument for this in that suicide can in extreme cases be the outcome of the stress of mental suffering occasioned by psycho-logical harassment or living abroad. Since the motive is not evident at the medical level, unqualified cover of suicide is the only way to provide cover for suicide committed under the various types of circumstance.15.  Clearer definition of the Article 73 cover for cold, freezing, insolation and other exposure to high or low temperatures.16.  Replacement (Article 4(1)) of the vague concept of intoxication by a precise reference to blood alcohol level, in the case of motor vehicle accidents that advocated by the Commission as the legal maximum in its Recommendation of 17 January 2001 on maximum permitted blood alcohol levels for drivers of motor vehicles [C(2000)4397]. For other accidents the maximum blood alcohol level to qualify for cover is 1.4 mg/ml. A driver with this level of alcohol in their blood has roughly twice the risk of having an accident as someone with a zero level.17.  In Article 4 paragraph 2 is added in order to specify that the disqualifying behaviour must have directly increased the risk of accident or occupational disease. This provision is taken over from the interpretative provisions adopted at the 82nd meeting of the Staff Regulations Committee (Brussels, 28 September 1984).18.  In Article 7(2) the third indent is deleted. Suicide is included in the new Article 2(2). It is considered that the unintentional mutilation and injuries previously mentioned here are accidents falling within the Article 2 definition.19.  In Article 10(2) (ex-Article 11) the wording is altered to obviate any misunderstanding about the lump sum to be paid should the insured party die as a result of an accident or occupational disease that has already given rise to payment of a lump sum. The sum now payable is the excess over the partial invalidity lump sum. Any other interpretation would entail discrimination between insured persons.20.  The Annex referred to in Article 11 (ex-Article 12) has been replaced. This was essential given advances in medical science and the need to use a single reference schedule instead of the two at present in use (the schedule of permanent partial invalidity rates appearing in the Annex itself and the Barème Officiel Belge des Invalidités (BOBI), the official Belgian invalidity rate schedule referred to in the third paragraph of the Annex).In addition the BOBI schedule (which exists only in French) is not known to non-Belgian doctors and for some disabilities there is a lack of consistency between the two schedules. Its antiquity makes it difficult for doctors to use and interpret and this can lead to different decisions by appointing authority doctors in similar situations.The new schedule proposed is the 'European Assessment Guide and Schedule for Physical and Mental Impairments' annexed to the proposal for a Council Recommendation that will be soon adopted by Parliament. This new schedule is the result of more than three years of work by a group of lawyers and doctors from the Member States working to terms of reference set by Parliament's Legal Affairs Committee. Annex B contains rules for using the schedule drawn up to guarantee consistent application of it in assessment of non-economic damage for the purposes of contract insurance schemes.The general level of the cover rates remains unchanged but the greater consistency of the schedule results in a number of changes from the present rates disability percentages. Generally speaking the changes are balanced, reflecting the need for assessment to take account of medical advances and the functional demands of contemporary activities.Paragraph 1 accordingly states that permanent invalidity will be assessed using the physical/mental impairment rates in the new European schedule (reproduced in the Annex except for its preface) and the rest of the Article is amended accordingly. Paragraphs 4, 5 and 6 are provisions of the Annex at present in force. Paragraph 5 has been reworded to make it clearer and more precise. An extension of cover to total or partial loss of function in the case of limbs or organs that function in synergy is similarly provided for with cover against the risk of occupational accident in the Member States.21.  Article 12 (ex-Article 13) now states how the annuity is to be paid. This is in line with current administrative practice whereby deferred interest is calculated following the annual payment.22.  Article 13 (ex-Article 14) expressly specifies the 'doctors appointed by the Institution' instead of the 'medical officers' in order to be consistent with the other Articles and avoid confusion with the JSIS doctors.The additional allowance can be granted for the impairments specified in the new European schedule (see Article 11) as open to separate assessment. The scope of these impairments is wider than previously since the new schedule specifies impairments other than physical/mental.Thus Article 13 now recognises aesthetic impairment, sexual impairment (apart from reproduction), exceptional non-assignable but medically plausible pain, and inability to engage in leisure activities specific to the insured party. There is a scale of 1 to 7 with rates ranging from 0.5 to 7%. This change eliminates the analogy to the Article 11 (ex-Article 12) invalidity scale which is impossible for the doctors to apply.23.  Article 15 (ex-Article 16) requires the insured person to provide evidence of the accident. Late declaration can be accepted in the event of force majeure or for any other lawful reason provided that a medical report on the accident or irrefutable evidence of its occurrence is provided.24.  Article 16 (ex-Article 17) specifies for occupational diseases the date to be used for the purpose of calculating the annual basic salary in application of Article 73. In contrast with accidents, where the date is clearly established, for occupational diseases determination of this date is a matter for medical assessment (judgment in Case T-88/91 F v Commission [1993] ECR II-13, points 35-39). In the absence of such a medical opinion the date of the declaration is to be used for the purpose of the calculation.25.  Article 17 (ex-Article 18) stipulates that except by reason of force majeure or for another legitimate reason failure of the insured person to comply with an invitation to attend issued by the appointed doctor entails closure of the dossier. This is a reasonable addition in the interests of sound administration, it being possible for the dossier to be reopened under Article 21 (ex-Article 22).26.  Article 19 (ex-Article 20) is now divided into numbered paragraphs and adds extra provisions applying to the period during which the injuries have stabilised, in particular an obligation on the insured person to keep the administration informed of his/her state of health.Closure of the dossier if no information is provided for more than six months is an additional provision added in the interests of sound administration. The dossier can always be reopened under Article 21 (ex-Article 22).The definition of stabilisation of the injuries inserted in paragraph 3 is taken from the interpretative provisions adopted at the 82nd meeting of the Staff Regulations Committee (Brussels, 28 September 1984).The possibility for the doctor appointed by the Institution to decide that stabilisation has occurred is inserted in response to medical requirements.Paragraph 4 allows a provisional invalidity payment to be made in occupational disease cases since the stabilisation concept is inapplicable.For accident cases paragraph 5 takes over the old Article 20 requirement that a provisional payment can be made if the degree of invalidity is at least 20%.27.  In paragraph 1 of Article 22 (ex-Article 23) the order of appointment of the doctors is altered in order to obviate any misunderstanding over the fact that the Institution appoints its doctor after appointment of the doctor of the insured party requesting that his/her case be considered by a Medical Committee. In the interests of sound administration and to avoid excessively large fees having to be paid to doctors this Article also requires that a detailed estimate be sought from them before appointment.The new paragraph 2 deals with the terms of reference given to the Medical Committee, which must consider the medical questions raised by the insured person's doctor, in line with Court of Justice case law (cf. judgment of 15 July 1997 in Case T-187/95 R v Commission). This paragraph also enables the appointing authority to curb the excessive fees of doctors, an indispensable provision given that the fees claimed are increasingly unpredictable (up to €18 000 for a Medical Committee session).Paragraph 3 provides a clearer description of procedure and of the organisation of the Committee's work and also indicates the third doctor's tasks, again in line with Court of Justice case law (cf. Case T-27/98 Nardone v Commission [1999] ECR-SC II-1293, paragraphs 68-69). Automatic notification of the Committee's report to the insured party is withdrawn since this is in contradiction with Article 20 (ex-Article 21). Its transmission at the request of the insured party or of those entitled under him or her completes the process of transmission from the Medical Committee. Transmission on request is consonant with Regulation (EC) No 45/2001 of the European Parliament and of the Council on the protection of individuals with regard to the processing of personal data by the Community institutions and bodies.Paragraph 4 simplifies the text and improves its overall consistency. As with Article 23 (ex-Article 24) payment of the costs for the Committee is governed by a single set of provisions irrespective of the type of accident (work or private life) and without the present text's discrimination between an accident at work and an occupational disease.28.  Introduction of an Article 24 on medical confidentiality. As in the case of the Joint Sickness Insurance Scheme a rule that the staff running the scheme must observe confidentiality is needed.Proposal for aCOMMON RULESon the insurance of officials of the European Communities against the risk of accident and of occupational diseaseTHE INSTITUTION(1),Having regard to the Staff Regulations of officials and the Conditions of Employment of other servants of the European Communities laid down by Regulation (EEC, Euratom, ECSC) No 259/68(2), as last amended by Regulation (EEC, Euratom) No XXXX/XX(3), and in particular Article 73 of the Staff Regulations and Article 28 of the Conditions of Employment,Having regard to the common rules on the insurance of officials of the European Communities against the risk of accident and of occupational disease, as last amended on 18 July 1997,Having regard to the opinion of the Staff Regulations Committee,Having regard to the common agreement of the Institutions of the European Communities(4),Whereas:It is the responsibility of the Institutions of the European Communities to draw up by agreement rules on insurance against the risk of accident and of occupational disease applicable to officials of the Communities,HAS ADOPTED THESE RULES:CHAPTER I GENERAL PROVISIONSArticle 1 SubjectThese rules lay down, pursuant to Article 73 of the Staff Regulations of the officials of the European Communities, the conditions under which insured parties are insured throughout the world against the risk of accident and of occupational disease.The following are insured under these rules:-  permanent officials;-  temporary staff;-  contract agents.Article 2 Accident29.  Subject to Article 7, an accident means any sudden occurrence adversely affecting the insured party’s bodily or mental health, the cause or one of the causes of which is external to the victim’s organism.30.  The following shall inter alia be considered accidents:31.  poisoning,32.  infections, sicknesses and injuries and any other consequences of the bites of animals or of the stings of insects,33.  sprains, tears or lacerations and ruptures of muscles or tendons caused by exertion,34.  the unexplained disappearance of an insured party, if on expiry of a period of one year and following an enquiry into the circumstances of the disappearance, the insured party is presumed dead unless there are grounds for presuming that the death was not due to an accident.Article 3 Occupational diseases35.  The diseases contained in the 'European schedule of occupational diseases' annexed to the Commission Recommendation of 19 September 2003(5) and any supplements thereto shall be considered occupational diseases to the extent to which insured parties have been exposed to the risk of contracting them in the performance of their duties with the European Communities.36.  Any disease or aggravation of a pre-existing disease not included in the List referred to in paragraph 1 shall also be considered an occupational disease if it is sufficiently established that such disease or aggravation arose in the course of or in connection with the performance by the insured parties of their duties with the Communities.Article 4 Exclusion from cover37.  Accidents shall not be covered by Article 73 of the Staff Regulations if they are due to the following causes:38.  subject to paragraph 3, wilful involvement of the insured party in a brawl;39.  manifestly reckless acts committed by the insured party or his/her participation by means of motorised equipment in sporting contests, races and official trials;40.  a blood alcohol level of the insured party who is the victim of an accident, of more than 0.5 mg/ml in the case of accidents resulting from the driving of any motor vehicle, and of more than 1.4 mg/ml in the case of any other accident;41.  the use by the insured party of drugs not prescribed by a doctor, except in case of error;42.  the deliberate handling by the insured party of military arms or ammunition, except in an emergency.43.  The exclusions referred to in paragraph 1 must be directly related to the aggravation of the risk(s) they cause.44.  Accidents listed in paragraph 1(a) shall be covered if they occur in the course of or in connection with the performance by insured parties of their duties or on their way to and from work, unless they are the inexcusable fault of the insured party.Article 5 Suspension of coverInsurance against the risks referred to in Article 73 of the Staff Regulations shall be suspended in the circumstances provided for in Article 40 of the Staff Regulations and Article 17 of the Conditions of Employment of other servants.Article 6 Deduction of benefitsIf an insured party sustains an accident or contracts a disease during a period for which he/she has been assigned non-active status or is on leave for military service pursuant to Articles 41 and 42 respectively of the Staff Regulations, benefits of the same kind paid from other sources shall be deducted from those payable under these rules.Article 7 Exclusion of benefits45.  The benefits referred to in Article 73 of the Staff Regulations shall not be payable if the accident or disease was caused intentionally by the insured party.No benefit shall be payable to a person entitled under the insured party where that person has intentionally caused the death of the insured party.46.  The following shall, however, be regarded as accidents within the meaning of these rules:47.  suicide;48.  bodily or mental injuries sustained in an emergency or in self-defence or when saving human life or salvaging property;49.  the consequences of assaults on or attempts on the life of the insured party, even in the course of strikes or disturbances unless it is proved that the insured part y participated of his / her own free will in the violent action in which he/she was injured, other than in self-defence.Article 8 SubrogationInsured parties or those entitled under them shall provide the institution to which the insured party belongs with any information or evidence available to them, in order to enable the institution, where appropriate, to take action against the third party, and give the institution all assistance necessary to this end. In order to seek an amicable settlement of their claims or to compound with the third party, the insured parties or those entitled under them shall obtain the consent of the institution to which the insured party belongs.CHAPTER II BENEFITSArticle 9 Reimbursement of expenses50.  Insured parties who sustain an accident or contract an occupational disease shall be entitled to reimbursement of all expenses necessary in order to restore as completely as possible their bodily or mental health and in order to pay for all care and treatment required as a result of the injuries sustained and their symptoms and also, where appropriate, of the expenses incurred in the functional and occupational rehabilitation of the victim.However, where the appointing authority of the institution to which the insured party belongs considers certain expenses excessive or unnecessary it may, on the advice of the doctor appointed by it, lower them to an amount considered reasonable or, where appropriate, refuse to reimburse them.The expenses referred to in the preceding subparagraphs shall be reimbursed to the insured party under these rules by the appointing authority of the institution to which the insured party belongs after the sickness insurance scheme provided for by Article 72 of the Staff Regulations has defrayed the part falling to that scheme under the conditions laid down therein.51.  The appointing authority of the institution to which the insured party belongs may, at his/her request and after consulting the doctor appointed by the appointing authority, reimburse travel expenses where it appears necessary for the insured party to be treated, spend his/her period of convalescence, or take a cure in his/her country of origin.In exceptional cases, where the insured party's state of health so requires, the appointing authority of the institution may, after consulting the doctor appointed by it, reimburse travel expenses in order to enable the insured party to receive the treatment necessitated by his/her state of health in a country other than his/her country of origin.Such travel expenses shall be reimbursed in accordance with Article 12 of Annex VII to the Staff Regulations.Article 10 Payment of a lump sum52.  Where an insured party dies as a result of an accident or occupational disease, the institution to which the insured party belongs shall pay the lump sum provided for in Article 73(2)(a) of the Staff Regulations to those entitled under him/her as therein designated.Where the insured party is found to be alive after all or part of this lump sum has been paid to those entitled in the case referred to in the last bullet point of Article 2(2), all sums paid shall be reimbursed by those entitled under him/her. Special arrangements may be made to effect such reimbursement.53.  Where, following payment of the lump sum provided for in Article 11, the insured party dies as a result of the same accident or the same occupational disease, the lump sum referred to in this Article shall be payable only in respect of the difference if that lump sum exceeds the lump sum paid pursuant to Article 11.Article 11 Permanent invalidity54.  Total or partial permanent invalidity shall be measured in terms of physical or mental impairments as laid down in the European disabilities rating scale, at Annex A to these rules.The practical rules for the use of the scale shown at Annex B shall apply.The Council recommendation on the adoption of a European disabilities rating scale and any supplements, excluding its preamble, shall replace Annex A to these rules on the day of its publication in the Official Journal of the European Union.55.  Where an insured party sustains total permanent invalidity as a result of an accident or an occupational disease, the physical or mental impairment shall be 100% and he/she shall be paid the lump sum provided for in Article 73(2)(b) of the Staff Regulations.56.  Where an insured party sustains partial permanent invalidity as a result of an accident or an occupational disease, he/she shall be paid a lump sum provided for in Article 73(2)(c) of the Staff Regulations and determined on the basis of the rates laid down in the scale referred to in paragraph 1 .57.  Injuries to limbs or organs previously disabled shall only be compensated by the difference between the condition before and that after the accident.58.  The assessment of injuries to healthy limbs or organs damaged in the accident shall be made taking into account the state of infirmity of other limbs or organs not affected by the accident and provided that those limbs or organs function in synergy with those damaged in the accident. In that case, the allowance shall cover the total or partial loss of the function.59.  The total allowance for invalidity on several counts arising out of the same accident shall be obtained through addition but such total shall not exceed either the total lump sum of the insurance for permanent or total invalidity or the partial sum insured for the total loss or the complete loss of use of the limb or organ injured.Article 12 AnnuityWhere insured parties or those entitled under them so request, an annuity shall be substituted for the payments provided for in Articles 10 and 11.That request shall be made within three months following notification of the decision provided for in Article 18.Conversion to an annuity, whether payable immediately or subsequently, shall be made on the basis of the pension tables provided for in Article 8 of Annex VIII to the Staff Regulations . Annuities shall be paid annually in arrears.Article 13 Additional allowanceAfter consulting the doctors appointed by the institutions or the Medical Committee referred to in Article 22, insured parties shall be granted an additional partial permanent invalidity allowance for physical disfigurement, sexual impairment (excluding reproductive impairment), exceptional pain and suffering not established objectively but medically plausible, and impairment of capacity to exercise leisure activities specific to the insured party.This allowance shall be determined on the basis of the scale for assessing specific forms of impairment contained in Annex C.Article 14 Flat-rate allowanceWhere, as a result of an accident or an occupational disease, the insured party is incapacitated to such an extent that he/she cannot do without the permanent assistance of another person, the appointing authority of the institution may, after consulting the doctor appointed by it or the Medical Committee referred to in Article 23, grant him/her a monthly flat-rate allowance equal to the justified expenditure and not exceeding 150% of the minimum subsistence figure referred to in Article 6 of Annex VIII to the Staff Regulations, account being taken of the weighting provided for in Article 64 of the Staff Regulations.The flat-rate allowance shall be paid only after the reimbursements payable for nursing expenses under Article 72 of the Staff Regulations have been exhausted and shall be paid as a supplement to such reimbursements.The decision to grant such an allowance shall be subject to review at intervals of not more than three years, to be determined by the institution.CHAPT ER III PROCEDUREArticle 15 Accident report60.  Insured parties who sustain an accident, or those entitled under them, shall report the accident to the administration of the institution to which the insured party belongs.Where the accident results in death or wherever it is impossible for the insured parties or those entitled under them to report the accident, this may be done by any member of their family or any other person with knowledge of the facts.The report of the accident shall state particulars on the date and time, the causes and the circumstances of the accident and also the names of witnesses and of any third party which may be liable. A medical certificate shall be annexed, specifying the nature of the injuries and the probable consequences of the accident.61.  The report shall be submitted not later than 10 working days following the date on which the accident occurs. However , in cases of force majeure or for any other lawful reason, and provided the insured party provides proof of the accident and establishes a causal link between the accident and the physical or mental impairment, this period may be extended.62.  The administration may hold an inquiry.Article 16 Statement of occupational disease63.  Insured parties who request application of these rules on grounds of an occupational disease shall submit a statement to the administration of the institution to which they belong within a reasonable period following the onset of the disease or the date on which it is diagnosed for the first time. The statement may be submitted by the insured party or, where the symptoms of the disease allegedly caused by the occupation become apparent after the termination of service, the former insured party; where an insured party dies as a result of a disease allegedly caused by his/her occupation, it may also be submitted by those entitled under him/her.The statement shall specify the nature of the disease and be accompanied by medical certificates or any other supporting documents.Where an occupational disease is confirmed, the benefits provided for in Article 73(2) shall be calculated on the basis of the monthly salary paid in the 12 months preceding the date on which the disease is first diagnosed or, failing that, the date on which the insured party first becomes incapable of working as a result of the disease or, failing that, the date of submission of the statement.64.  The Administration shall hold an enquiry in order to obtain all the particulars necessary to determine the nature of the disease, whether it has resulted from the insured party's occupation and also the circumstances in which it has arisen.An enquiry may be held automatically in the case of an insured party who contracts a disease or sustains injuries by exposure, in the performance of his/her duties, to noxious substances or to exceptional factors causing disease.After seeing the report drawn up following the enquiry, the doctor(s) appointed by the institutions shall state his/her/their findings as provided for in Article 18.Article 17 Expert medical opinionThe Administration may obtain any expert medical opinion necessary for the implementation of these rules.Failure to attend a consultation called by the doctor appointed by the institution shall lead to the termination of the case, except in case of force majeure or for any other lawful reason and subject to the application of Article 21.Article 18 DecisionsDecisions recognising the accidental cause of an occurrence including a decision as to whether the occurrence is to be attributed to occupational or non-occupational risks, or decisions recognising the occupational nature of a disease and assessing the degree of permanent invalidity shall be taken by the appointing authority in accordance with the procedure laid down in Article 20:-  on the basis of the findings of the doctor(s) appointed by the institutions; and-  where the insured party so requests, after consulting the Medical Committee referred to in Article 22.Article 19 Consolidation of injuries65.  Insured parties shall be required to inform the Administration of any change in their state of health by submitting medical certificates.66.  If insured parties provide no information under paragraph 1 for more than 6 months, they will be presumed to have recovered and the case will be terminated, subject to the application of Article 21.67.  The decision defining the degree of invalidity shall be taken after the insured party's injuries have consolidated. The consequences of the accident or occupational disease shall be considered consolidated where they have stabilised or will diminish only very slowly and in a very limited way. To this end, the insured party concerned shall submit a medical report stating that he/she has recovered or that his/her condition has stabilised and also setting out the nature of the injuries. However, the doctor(s) appointed by the institution or the Medical Committee referred to in Article 22 may decide that consolidation has taken place, including in the absence of this medical report.Where it is impossible to define the degree of invalidity after medical treatment is terminated, the findings of the doctor(s) referred to in Article 18 or, where appropriate, the report of the Medical Committee referred to in Article 22 must specify a deadline for reviewing the insured party’s case.68.  Where an occupational disease is confirmed , the appointing authority shall grant a provisional allowance corresponding to the undisputed proportion of the permanent invalidity rate. That allowance shall be set off against the final benefit.69.  The provision contained in paragraph 4 shall apply to decisions concerning accidents where the degree of invalidity is not less than 20%.Article 20 Draft decision and request for consultation of the Medical Committee70.  Before taking a decision pursuant to Article 18, the appointing authority shall notify the insured party or those entitled under him/her of the draft decision and of the findings of the doctor(s) appointed by the institution. The insured party or those entitled under him/her may request that the full medical report be communicated to them or to a doctor chosen by them.71.  Within a period of 60 days the insured party or those entitled under him/her may request that the Medical Committee provided for in Article 22 deliver its opinion. The request for the matter to be referred to the Medical Committee shall contain the name of the doctor representing the insured party or those entitled under him/her together with a report from that doctor setting out the medical issues disputed in relation to the doctor(s) appointed by the institution for the purposes of applying these rules.72.  Where, on expiry of this period, no request has been made for consultation of the Medical Committee, the appointing authority shall take a decision in accordance with the draft previously supplied.Article 21 Re-opening of a caseInsured parties may at any time submit a statement concerning the aggravation of their injuries or invalidity and concerning cases that have been terminated pursuant to the second paragraph of Article 17 and Article 19(2), accompanied by a report from their personal physician.Where such aggravation is confirmed by the doctor appointed by the appointing authority, the latter shall decide on the matter in accordance with the procedure laid down in Articles 18 and 20.Article 22 Medical Committee73.  The Medical Committee shall consist of three doctors:74.  one appointed by the insured party or those entitled under him/her;75.  one appointed by the appointing authority;76.  one appointed by agreement between the first two doctors.Where agreement cannot be reached on the appointment of the third doctor within a period of two months following the appointment of the second doctor, the President of the Court of Justice of the European Communities shall appoint the third doctor at the request of either party.Irrespective of the method of appointment, the third doctor shall have proven expertise in assessing and treating bodily injury.77.  The institution shall provide the Medical Committee with its terms of reference. These shall cover medical matters raised by the report from the doctor representing the insured party or those entitled under him/her and other relevant medical reports transmitted under Article 20(2).Before commencing work, and within 15 working days following the date on which the Medical Committee is given its terms of reference, the doctor appointed by the official and the third doctor shall provide the institution with an estimate of their fees and expenses. The appointing authority shall give its consent to these fees and expenses. The institution may set varying upper limits depending on the complexity of the terms of reference. The fees and expenses of the third doctor which do not obtain the consent of the institution shall be notified for agreement to the insured party or those entitled under him/her who requested the consultation of the Medical Committee. If the fees and expenses of the third doctor are not agreed to by the insured party or those entitled under him/her, a new appointment shall be made in accordance with paragraph 1. Where the insured party or those entitled under him/her agree to the fees and expenses, the terms of reference shall be confirmed to the doctor.Before confirming the terms of reference to the doctors, the institution shall inform the insured party or those entitled under him/her of the fees and expenses which are liable to be borne by them in accordance with paragraph 4. The insured party or those entitled under him/her may not under any circumstances object to the third doctor on account of the amount of the fees and expenses requested by him/her. However, the insured party shall be free at all times to discontinue the procedure for referral to the Medical Committee. In that case, the fees and incidental expenses of the doctor chosen by the insured party or those entitled under him/her and half of the fee and incidental expenses of the third doctor, shall be borne by the insured party or those entitled under him/her in respect of the part of the work that has been completed.The insured party or those entitled under him/her shall remain liable to his/her doctor for sums agreed with him/her, irrespective of what the institution agrees to pay.78.  The Medical Committee shall examine collectively all the available documents liable to be of use to it in its assessment and all decisions shall be taken by majority vote. The Medical Committee shall be responsible for deciding on and adopting its own rules of procedure. The third doctor shall be responsible for providing the secretariat and drafting the report. The Medical Committee may request additional examinations and consult experts in order to complete the case or obtain opinions which are necessary for carrying out its task.The Medical Committee may deliver medical opinions only on the facts submitted to it for examination or which are brought to its attention.If the Medical Committee, whose task is limited to the purely medical aspects of the case, considers that it may entail a legal dispute, it shall declare that it does not have competence to deal with the matter.On completing its proceedings, the Medical Committee shall set out its opinion in a report to the appointing authority.On the basis of that report, the appointing authority shall notify the insured party or those entitled under him/her of its decision together with the findings of the Medical Committee. The insured party and those entitled under him/her may request that the Committee’s full report be transmitted to a doctor of their choice or that it be communicated to them.79.  Expenses incurred in connection with the proceedings of the Medical Committee shall be borne by the institution to which the insured party belongs.However , where the opinion of the Medical Committee is in accordance with the draft decision of the appointing authority insured parties or those entitled under them shall pay the fees and incidental expenses of the doctor chosen by them and half of the fee and incidental expenses of the third doctor, whilst the remainder shall be borne by the institution.80.  In exceptional cases and by a decision taken by the appointing authority after consulting the doctor appointed by it, all the expenditure referred to in the preceding paragraphs may be borne by the institution.Article 23 Consulting another doctor81.  In cases other than those referred to in Article 18, where a decision is to be taken after consulting the doctor appointed by the appointing authority, the latter shall, before taking such a decision, notify the insured party or those entitled under him/her of the draft decision and also of the doctor's findings. Within a period of 30 days the insured party or those entitled under him/her may request consultation of another doctor, to be chosen by agreement between the doctor appointed by the appointing authority and the doctor appointed by the insured party or those entitled under him/her. If, on the expiry of that period, no request for such consultation has been made, the appointing authority shall take a decision in accordance with the draft previously notified.The opinion of the doctor referred to in the preceding subparagraph shall be communicated by the appointing authority to the insured party or those entitled under him/her.82.  The expenses incurred in consulting the doctor chosen by agreement shall be borne by the institution to which the insured party belongs.However, where the opinion of that doctor is in accordance with the draft decision of the appointing authority, the insured party or those entitled under him/her shall pay the fee and incidental expenses involved in such consultation.Article 24 ConfidentialityStaff assigned to administering these rules shall be required to observe confidentiality regarding medical documents and/or expenses which come to their attention in the course of the performance of their tasks.They shall continue to be subject to this obligation after their duties have ceased under these rules.Article 25 Independence of Article 73Recognition of total or partial permanent invalidity pursuant to Article 73 of the Staff Regulations and to these rules shall in no way prejudice application of Article 78 of the Staff Regulations and vice versa.CHAPTER IV SETTLEMENT OF CLAIMS AND PAYMENT OF BENEFITSArticle 26 Settlement of claimsAny claims accruing under these rules to an insured party who sustains an accident or contracts an occupational disease or to those entitled under him/her shall be settled by the institution to which the insured party belonged at the time when he/she sustained the accident or contracted the occupational disease. A breakdown of such settlement shall be sent to the insured party or to those entitled under him/her and also to the Commission of the European Communities, which is responsible for paying the benefits provided for in these rules.Article 27 Payment of benefitsThe lump sums referred to in Articles 10 and 11 and the annuity referred to in Article 12 shall be paid in euro.CHAPTER V APPEALSArticle 28 AppealsDecisions taken under these rules may be the subject of a complaint under Article 90 of the Staff Regulations by the insured party or those entitled under him/her to the appointing authority of the institution to which the insured party belongs and of an appeal by the same persons to the Court of Justice of the European Communities under the conditions laid down in the Treaties establishing the Communities and in Article 91 of the Staff Regulations.CHAPT ER VI FINAL PROVISIONSArticle 29 Regular concertationThe Staff Regulations Committee shall consider the application of these rules at regular intervals.Article 30 RepealThe joint Rules on the insurance of officials of the European Communities against the risk of accident and of occupational disease, last amended on 18 July 1997, are hereby repealed .However, they shall continue to apply to all draft decisions adopted under Article 20(1) before 1 XXX 2004, save where a case is re-opened under Article 21 .Article 31 Entry into forceThese rules shall enter into force on the first day of the month following that in which the agreement between the institutions provided for in Article 73(1) of the Staff Regulations of Officials is recorded by the President of the Court of Justice.They shall apply as of the same date.ANNEX AProposed European disability rating scale25 MAY 2003CONTENTSI. Nervous system ________________________________________________________NeurologyPsychiatrySensorimotor deficitsII. Sensory system and stomatology __________________________________________Ophthalmology __________________________________________________________ENTStomatology ____________________________________________________________III. Osteoarticular system ____________________________________________________Upper limb _____________________________________________________________Lower limb ______________________________________________________________Spine __________________________________________________________________Pelvis __________________________________________________________________IV. Cardiorespiratory system _________________________________________________HeartLungsV. Vascular system _________________________________________________________Arteries ________________________________________________________________Veins _________________________________________________________________Lymph vessels ___________________________________________________________Spleen _________________________________________________________________VI. Digestive system _______________________________________________________Liver, gastroenterologyVII. URINARY SYSTEM _________________________________________________________VIII. Reproductive system ____________________________________________________IX. Endocrine system ______________________________________________________X. Skin __________________________________________________________________Deep burns or pathological scarring __________________________________________I. NERVOUS SYSTEM |I – NERVOUS SYSTEMSituations not described are assessed by comparison with clinical situations which are described and quantified.Where the Scale envisages complete deficit only, partial sequelae should be assessed on the basis of the deficit observed, with reference to the rating for total loss.NEUROLOGYMotor and sensorimotor sequelaeComplete tetraplegia, depending on level C2 to C6 below C6 | 95% 85% |Complete hemiplegia with aphasia without aphasia | 90% 75% |Complete paraplegia, depending on level | 70 to 75% |Complete cauda equina impairment, depending on level | 25 to 50% |Cognitive disorders-  Analysis of neuropsychological deficit syndromes has to refer to precise signs and concepts. So-called ‘frontal’ syndrome corresponds in fact to entities which are now well defined and whose associated deficits of varying severity produce extremely polymorphic clinical pictures.It is thus essential that assessment of the rate of disability should be based on precise specialist medical reports which correlate the initial lesions with the data from clinical and paraclinical examinations.True frontal syndromeMajor form with apragmatism with serious impairment of ability to form and sustain social and family relationships | 60 to 85% |Severe form with changes in instinctual behaviour, loss of initiative, mood disorders, precarious social and family relationships | 35 to 60% |Moderate form with relative bradypsychia, memorisation difficulty, mood disorders and repercussions on social and family relationships | 20 to 35% |Minor form with distractibility, slowness, difficulty in memorisation and grasping complex ideas. Little or no impairment of ability to sustain social and family relationships | 10 to 20% |2) Communication disordersMajor aphasia with jargonaphasia, alexia, disturbances of comprehension | 70% |Minor form: disturbances of naming and repetition, paraphasia. Comprehension is retained | 10 to 30% |3) Memory disordersFull Korsakoff’s syndrome | 60% |Associated disorders: frequent forgetfulness, a handicap in everyday living requiring the subject to use aides-mémoire, perceptual distortion, possibly confabulation, difficulty in mastering new tasks, problems with recall | 10 to 60% |Total or partial loss of didactically acquired knowledge: Ratings for this should be assessed using the same scale as for memory disorders. |4) Minor cognitive disordersWhere there is no true frontal syndrome or isolated impairment of a cognitive function, certain cranial traumas of varying severity may give rise to objectively measurable symptoms which constitute a syndrome different from postconcussion syndrome, with:Short attention span, slowness of thought, memorisation difficulty, rapid mental tiredness, intolerance to noise, mood swings, lasting longer than 2 years | 5 to 10% |5) DementiaTrauma has not been proved to trigger dementia. Alzheimer’s disease and senile dementia are never the result of trauma.Mixed cognitive and sensorimotor deficitsThese mixed deficits are typical sequelae of severe cranial trauma. In most cases they combine frontal dysfunctions with cognitive deficits, behavioural disturbances, pyramidal and/or cerebellar syndromes or sensory disturbances (hemianopsia, oculomotor paralysis, etc.) consistent with the lesions visualised by medical imaging.These associations produce clinical pictures which differ from one subject to another, to the point where one cannot suggest precise ratings in the way one can for fully personalised sequelae. These deficits will be assessed on an overall basis.It is possible, however, in the context of medico-legal assessment, to identify several levels of severity in relation to the overall deficit.Loss of all useful voluntary activity, loss of all identifiable relational abilities | 100% |Major sensorimotor deficits seriously limiting independence, in conjunction with cognitive deficits incompatible with a reasonable relational life | 85 to 95% |Major cognitive disorders comprising primarily lack of inhibition and severe behavioural disorders which compromise all social interactions, with sensorimotor deficits compatible with independence in the essential actions of everyday living | 60 to 85% |Cognitive disorders in conjunction with permanent disturbance of attention and memory, relative or total loss of initiative and/or self-criticism, inability to manage complex situations, with sensorimotor deficits which are patent but compatible with independence in the actions of everyday living | 40 to 60% |Cognitive disorders which combine obvious slowness of thought, patent memory deficit, difficulty in grasping complex ideas with minor sensorimotor deficits | 20 to 40% |EpilepsyOne cannot suggest a disability rating until cranioencephalic trauma and epileptic seizures have been confirmed, and until the necessary time has elapsed to stabilise the condition’s spontaneous progression and render the patient suitable for treatment .1) Epilepsy with loss of consciousness(Generalised epilepsy and complex partial epilepsy)Epilepsy which is not controllable despite appropriate drug treatment and followed by established, almost daily seizures | 35 to 70% |Epilepsy which is hard to control, with frequent seizures (several a month), and secondary effects from treatment | 15 to 35% |Epilepsy which is well controlled by treatment which is well tolerated | 10 to 15% |Epilepsy without loss of consciousnessEpilepsy which is partial and simple, authenticated as such by type and frequency of seizures and the secondary effects of treatment | 10 to 30% |Isolated EEG abnormalities, in the absence of established seizures, do not allow a diagnosis of post-traumatic epilepsy to be postulatedPostconcussion syndromeSymptoms reported but not confirmed objectively following an established loss of consciousness | 2% |Deafferent pain:This is pain linked to a lesion of the peripheral nervous system, which is felt without any nociceptive stimulation and may be one of several clinical types:anaesthesia dolorosa, severe acute pain, hyperpathia (e.g. phantom limb pain or trigeminal neuralgia).These are types of ‘exceptional pain’ which are not part of the customary post-traumatic picture and so are not included in the disability ratings. They are a secondary form of damage.Nevertheless there would seem to be a case for assessing them by increasing the disability rating for the deficit concerned by a further 5 to 10%.***PSYCHIATRY(By reference to ICD-X and DSM-IV)a) Persistent mood disordersIn the case of post-traumatic physical lesions requiring complex and protracted treatment with severe sequelae, there may be permanent mental suffering in the form of persistent mood disorders ( depressive state ) :Frequent medical monitoring by a specialist, major drug treatment required with or without hospitalisation | 10 to 20% |Regular medical monitoring by a specialist with sporadic specific drug treatment | 3 to 10% |Necessitating medical monitoring at irregular intervals with intermittent treatment | up to 3% |83.  Traumatic neurosis (post-traumatic stress syndrome, fright neurosis)These follow mental symptoms triggered by the sudden, unexpected and brutal occurrence of a traumatic event with which the individual is unable to cope.The stress factor must be intense and/or protracted.The event must have been memorised.The body of symptoms includes phobic anxiety, avoidance behaviour, obsessive-compulsive disorder and personality change. Even if treated very early, this cannot be assessed earlier than two years or so after the event.Full-blown phobia syndrome | 12 to 20% |Phobic anxiety with panic attacks, avoidance behaviour and obsessive-compulsive disorder | 8 to 12% |Phobic anxiety symptoms with avoidance behaviour and obsessive-compulsive disorder | 3 to 8% |Minor phobic anxiety symptoms | up to 3% |84.  Psychotic disordersThese are not considered further in the Scale since they have hardly ever been shown to be the result of trauma.***C) SENSORIMOTOR DEFICITSDamage to the nervous system entails paralysis (total lesion) or paresis. It must be assessed in terms of its objectively measured clinical and technical repercussionsa) FaceParalysis of the trigeminal nerve unilateral bilateral | 15% 30% |Paralysis of the facial nerve unilateral bilateral | 20% 45% |Paralysis of the glossopharyngeal nerve unilateral | 8% |Paralysis of the hypoglossal nerve unilateral | 10% |-  b) Upper limbD | ND |Total paralysis (complete lesion of the brachial plexus) | 65% | 60% |Paralysis of the median-ulnar nerve | 45% | 40% |Paralysis of the radial nerve above the tricipital branch below the tricipital branch | 40% 30% | 35% 25% |Paralysis of the median nerve arm wrist | 35% 25% | 30% 20% |Paralysis of the ulnar nerve | 20% | 15% |Paralysis of the circumflex nerve | 15% | 12% |Paralysis of the musculocutaneous nerve | 10% | 8% |Given their implications for the upper limb the following impairments have been included in this chapter:D | ND |Paralysis of the spinal nerve | 12% | 10% |Paralysis of the superior thoracic nerve | 5% | 4% |85.  Lower limbTotal paralysis of the sciatic nerve (complete lesion) high truncal form (with paralysis of the gluteal nerves) low form, below the knee | 45% 35% |Paralysis of the femoral nerve | 35% |Paralysis of the fibular nerve | 22% |Paralysis of the tibial nerve | 22% |Paralysis of the obturator nerve | 5% |-  ***II. SENSORY SYSTEM and STOMATOLOGY |II. SENSORY SYSTEM AND STOMATOLOGY1 - OPHTHALMOLOGYSituations not described are assessed by comparison with clinical situations which are described and quantified.A) VISUAL ACUITYa) Total loss of visionLoss of vision in both eyes (blindness) | 85% |Loss of vision in one eye | 25% |b) Loss of visual acuity in both eyes, distance and near visionQuadranopsia depending on type | up to 30% |Central scotoma bilateral unilateral | up to 70% up to 20% |Juxta-central or paracentral scotoma depending on whether it is uni- or bilateral with visual acuity preserved | up to 15% |-  C) EYE MOVEMENTDiplopia depending on direction of gaze, whether or not the condition is permanent, whether or not one eye needs to be covered at all times | up to 25% |Oculomotor paralysis depending on type | up to 15% |Intrinsic movement depending on type (maximum total aniridia) | up to 10% |Heterophoria; total paralysis of convergence | 5% |-  D) LENSLoss (aphakia) corrected by spectacles or contact lenses bilateral unilateral To which should be added the rating for the corrected loss of visual acuity, without exceeding 25% for a unilateral lesion and 85% if both eyes are affected. Loss corrected by a lens implant (pseudophakia) : add 5% for each pseudophakic eye to the ratings for loss of visual acuity | 20% 10% |-  E) ADNEXA OF THE EYEDepends on the impairment, the most serious being ptosis with campimetric deficit and bilateral alacrimia | up to 10% |***2 - ENTSituations not described are assessed by comparison with clinical situations which are described and quantified.A) HEARINGa) Auditory acuity1) Total deafnessBilateral | 60% |Unilateral | 14% |2) Partial deafnessAssessment is in 2 stages:-  Mean hearing lossThis is assessed by reference to the air conduction tonal deficit measured in decibels at 500, 1000, 2000, and 4000 hertz, applying weightings of 2, 4, 3 and 1 respectively. The sum is divided by 10.Refer to the table below.Mean hearing loss in dB | 0 - 19 | 20 - 29 | 30 -39 | 40 - 49 | 50 - 59 | 60 - 69 | 70 - 79 | 80 + |0 - 19 | 0 | 2 | 4 | 6 | 8 | 10 | 12 | 14 |20 - 29 | 2 | 4 | 6 | 8 | 10 | 12 | 14 | 18 |30 - 39 | 4 | 6 | 8 | 10 | 12 | 15 | 20 | 25 |40 - 49 | 6 | 8 | 10 | 12 | 15 | 20 | 25 | 30 |50 - 59 | 8 | 10 | 12 | 15 | 20 | 25 | 30 | 35 |60 - 69 | 10 | 12 | 15 | 20 | 25 | 30 | 40 | 45 |70 - 79 | 12 | 14 | 20 | 25 | 30 | 40 | 50 | 55 |80 + | 14 | 18 | 25 | 30 | 35 | 45 | 55 | 60 |-  Auditory distortionAssessment must compare this crude rating with the results of speech audiometry to assess any auditory distortions (recruitment in particular) which makes the functional impairment worse.The table below suggests increased ratings which might be considered in the light of the results of pure tone threshold audiometry:% discrimination | 100% | 90% | 80% | 70% | 60% | ( 50% |100% | 0 | 0 | 1 | 2 | 3 | 4 |90% | 0 | 0 | 1 | 2 | 3 | 4 |80% | 1 | 1 | 2 | 3 | 4 | 5 |70% | 2 | 2 | 3 | 4 | 5 | 6 |60% | 3 | 3 | 4 | 5 | 6 | 7 |( 50% | 4 | 4 | 5 | 6 | 7 | 8 |Where a hearing aid is worn, the improvement will be determined by comparing the auditory curves obtained with and without the hearing aid in place; it enables the rating to be reduced, but account must be taken of the nuisance value of the prosthesis, especially in a noisy environment .86.  Isolated tinnitusIf confirmed as imputable to trauma | up to 3% |B) BALANCEBilateral vestibular impairment, with objectively confirmed destruction, depending on severity | 10 to 25% |Unilateral vestibular impairment | 4 to 10% |Benign paroxysmal vertigo | up to 4% |C) NASAL BREATHINGUntreatable obstruction bilateral unilateral | up to 8% up to 3% |-  D) OLFACTORY SENSEincluding altered sense of tasteAnosmia | 8% |Hyposmia | up to 3% |E) SPEECHAphonia | 30% |Isolated dysphonia | up to 10% |***3 - STOMATOLOGYSituations not described are assessed by comparison with clinical situations which are described and quantified.For a removable prosthesis reduce by 1/2; for a fixed prosthesis reduce by 3/4.Where an implant is fitted there is deemed to be no disability.Loss of all teeth where it is clear that prosthetic replacement is not possible bearing in mind the implications for general health | 28% |Loss of a tooth, prosthetic replacement not possible incisor or canine premolar or molar | 1% 1.5% |Mandibular dysfunction mouth can open no wider than 10 mm mouth can open no wider than 10 to 30 mm | 25 to 28% 5 to 25% |Post-traumatic misalignment of teeth, depending on its effect on the ability to chew | 2 to 10% |Amputation of the mobile part of the tongue, bearing in mind its effect on speech, chewing and swallowing, depending on the severity of dysfunction. | 3 to 30% |***III. OSTEOARTICULAR SYSTEM |III – OSTEOARTICULAR SYSTEMSituations not described are assessed by comparison with clinical situations which are described and quantified.In the case of a joint or the limb itself, the overall rating is not the sum of the separate ratings but the result of their synergy, and the sum of the ratings for ankylosis of all the joints of a limb in a good position may not be higher than the value for total anatomical or functional loss of the limb.Ratings justified by very severe stiffness not systematically provided for should be based on the rating for ankylosis of the relevant joint.As regards endoprostheses for the major joints, it must be acknowledged that none of them restores proprioception and all of them impose certain restrictions on the lifestyle of the person concerned. Consequently, the presence of an endoprosthesis justifies a rating in principle of 5%.Where the objective functional result is not satisfactory, these inconveniences in principle of the endoprosthesis are automatically included with those of the functional deficit, and this additional rating is not then justified.A) UPPER LIMB(excluding hand and fingers)a) AmputationsCurrent possibilities for prosthetic replacement of the upper limbs do not generally speaking restore true function to the patient, since he cannot regain sensation. Where there is an improvement, the expert will take specific account of this and make a reasonable reduction in the rating suggested belowD | ND |Total amputation of upper limb | 65% | 60% |Amputation of arm (shoulder mobile) | 60% | 55% |Amputation of forearm | 50% | 45% |b) Ankylosis and stiffness1) ShoulderThere are 6 pure shoulder movements which, together, enable the joint to function. Each of these movements has its own relative importance in the actions of everyday living.The 3 essential movements are anterior elevation, abduction and internal rotation followed by external rotation, retropulsion and adduction. Impairments of retropulsion and adduction justify ratings so minimal that they are not included in the table below. They serve to weight the rating calculated for limitations of the other movements.-  AnkylosisD | ND |Arthrodesis or ankylosis in functional position shoulder blade fixed shoulder blade mobile | 30% 25% | 25% 20% |-  StiffnessD | ND |Elevation and abduction limited to 60° with total loss of rotation other movements fully possible | 22% 18% | 20% 16% |Elevation and abduction limited to 90° with total loss of rotation other movements fully possible | 16% 10% | 14% 8% |Elevation and abduction limited to 130° other movements fully possible | 3% | 2% |Isolated loss of internal rotation | 6% | 5% |Isolated loss of external rotation | 3% | 2% |2) ElbowOnly mobility between 20 and 120 degrees of flexion is of any practical use. Movements outside this useful range have only very minimal relevance for everyday life.Thus the ratings below apply only to deficits within this range.The expert will take account of the extension deficit and flexion deficit, the ratings for these being necessarily considered together though not added together. The rating for any pronosupination deficit may be added.-  AnkylosisD | ND |Arthrodesis or ankylosis in functional position pronosupination preserved pronosupination lost | 24% 34% | 20% 30% |-  StiffnessD | ND |Full flexion, and extension limited beyond 90° limited to 90° limited to 20° | 15% 12% 2% | 12% 10% 1% |Full extension, and flexion up to 120° up to 90° beyond | 2% 12% 15% | 1 % 10% 12% |3) Isolated impairment of pronosupination-  AnkylosisD | ND |Ankylosis in functional position | 10% | 8% |-  StiffnessD | ND |Stiffness in pronation range | 0 to 6% | 0 to 5% |Stiffness in supination range | 0 to 4% | 0 to 3% |4) WristThe useful range extends from 0 to 45 degrees for both flexion and extension. Movements outside this useful range have only very minimal relevance for everyday life. The same is true of radial deviation.-  AnkylosisD | ND |Arthrodesis or ankylosis in functional position pronosupination preserved pronosupination lost | 10% 20% | 8% 16% |-  StiffnessD | ND |Stiffness in useful range flexion deficit extension deficit | 0 to 4% 0 to 6% | 0 to 3% 0 to 5% |Loss of ulnar deviation | 1.5% | 1% |B HANDThe essential function of the hand is prehension, determined by the efficient performance of grasping and gripping movements. These require the possession of fingers of adequate length, mobility and sensitivity.The expert will primarily need to make an analytical examination of the hand.He will then have to check that his findings on examination are borne out by the patient’s ability to perform the six basic grasping and gripping actions (see figure).Any discrepancy should prompt careful investigation of its causes and a possible adjustment to the disability rating envisaged, the absolute limit being the loss of value of the fingers concerned.PRINCIPAL GRASPING AND GRIPPING ACTIONS[pic] [pic] [pic]Power grip, palmar Precision grip, (sub)terminal Precision grip,opposition subtermino-lateral[pic] [pic] [pic] Dynamic tripod Hook grip Power ball gripa) Amputations1) Total amputation of the handD | ND |Total amputation of the hand | 50% | 45% |2) Amputation of the fingersIn this diagram:-  the dotted areas are valued at nil-  the rating attributed to each segment covers the whole of that segment-  partial loss of a segment is calculated pro rata as a proportion of the rating for total loss-  the ratings suggested take account of the minor changes in sensitivity, blood supply and shape which the doctor knows to be usual with finger amputations-  Amputation of the thumb (and its metacarpal) or long fingers: see diagram of hand-  Amputation of a long finger (total or partial) : see rating on diagram.-  Amputation of several long fingers (combined losses): simply adding together the calculated ratings for single fingers does not take account of the interaction of the long fingers. This synergy is different depending on the number of fingers involved:-  loss of 2 long fingers: increase the simple total by 45% of the rating calculated-  loss of 3 long fingers: increase the simple total by 65% of the rating calculated-  loss of 4 long fingers: increase the simple total by 45% of the rating calculated-  Amputation of the thumb :D | ND |loss of MC + P1 + P2 | 26% | 22% |loss of P1 + P2 | 21% | 18% |loss of P2 | 12% | 10% |-  Amputation of the thumb and one or more of the long fingers: here the term ‘thumb’ refers only to P1 + P2.Simply adding together the ratings for the thumb and all the long fingers lost (calculation of this latter rating takes account of the interaction of the long fingers) would give an overall rating which was too high. The value attributed to the thumb in the diagram of the hand only applies if the long fingers are intact. If they are not, the thumb loses part of its usefulness in the synergistic action of all 5 digits.Thus, the following reducing factors should be applied to the rating arrived at by simply adding together the rating for the thumb + the rating for the long fingers increased for their synergistic action:-  loss of thumb and 1 finger: 0% (impairment too minor to count in the calculation)-  loss of thumb and 2 fingers: - 5%-  loss of thumb and 3 fingers: -10%-  loss of thumb and 4 fingers: -20%Loss of the first metacarpal as well will have little effect on the final rating: the first metacarpal on its own is of little value.The effect on the final rating for the other metacarpals is modest but variable since, depending on the case, resection of them will be desirable or slightly counterproductive.b) Ankylosis, arthrodesis and stiffnessWhere there is combined impairment of several fingers the proposed factors should be applied to take account first of the synergy between the long fingers and, second, of impairment affecting both the thumb and one or more of the long fingers: see earlier text.1) AnkylosisBy convention the trapezometacarpal joint of the thumb is called A0; for all the fingers A1 is the metacarpophalangeal joint, A2 the proximal interphalangeal joint, and A3 the distal interphalangeal joint.The functional position for the long fingers is flexion of 20 to 30°.The functional position for the thumb is abduction and antepulsion of A0 and slight flexion of A1 and A2.-  Ankylosis of the thumb in the functional positionAnkylosis of A0, A1 and A2 gives a rating of less than 75% of the value of the finger used for ankylosis of the long fingers, taking into account the special function of the thumb. Even with this ankylosis a degree of opposing force can still be exerted.D | ND |A0 + A1 +A2 | 16% | 14% |A0 | 8% | 7% |A1 | 4% | 3.5% |A2 | 4% | 3.5% |A1 + A2 | 8% | 7% |-  Ankylosis of all the joints of a long fingerIn the functional position : equivalent to 75% of the value of the finger’s loss, given that sensation is retained and limited use of the finger is still possibleD | ND |Index finger | 6% | 5% |Middle finger | 6% | 5% |Ring finger | 4% | 3% |Little finger | 4.5% | 4% |In a poor positionoverflexed | D | ND |Index | 8% | 7% |Middle finger | 8% | 7% |Ring finger | 5% | 4% |Little finger | 6% | 5% |overextended | D | ND |Index finger | 7% | 6% |Middle finger | 7% | 6% |Ring finger | 4.5% | 3.5% |Little finger | 5% | 4% |-  Ankylosis of one or more joints of a long fingerThe expert will look at the rating for total ankylosis of the finger concerned less 1/3 or 2/3.2) StiffnessThe rating given for stiffness is a proportion of the rating for ankylosis, taking into account the normal range of mobility of each joint.The normal range of mobility for the long fingers is:-  A1 and A2: index and middle finger: 20 to 80°; ring finger and little finger: 30 to 90°-  A3: 20 to 70°The normal range of mobility for the joints of the thumb lies on either side of their functional position.c) Disorders of palmar sensitivityDisordered sensitivity of the back of the hand has no implications for function, so it does not justify a disability rating.The ratings proposed cover slight paraesthesia and discrete abnormalities of shape which the doctor knows to be normal in minor neuromas following resection of a nerve.Where several fingers are involved, the factors for synergy of the long fingers and for loss of both thumb and one or more of the long fingers should be applied: see earlier text.1) Anaesthesia : the rating given is 75% of the rating for anatomical loss of the segment(s) of the finger(s) in question.2) Hypoaesthesia : the rating given is 50% to 75% of the rating for anatomical loss of the segment(s) of the finger(s) in question, depending on the severity and localised extent of hypoaesthesia and the finger affected (ability to grip).B) LOWER LIMBa) AmputationsDisarticulation of the hip or high-level transfemoral amputation where a prosthesis cannot be fitted | 65% |Unilateral disarticulation of the hip or high-level transfemoral amputation without ischial support | 60% |Femoral amputation | 50% |Disarticulation of the knee | 40% |Amputation of the leg | 30% |Tibiotarsal amputation | 25% |Mid- or transmetatarsal amputation | 20% |Amputation of the 5 toes and 1st metatarsal | 12% |Amputation of the big toe and 1st metatarsal | 10% |Amputation of both phalanges of the big toe | 6% |Amputation of a lower limb, unless it is the foot, renders the patient unable to walk or stand. The suggested ratings are for a patient correctly fitted with a prosthesis. If the prosthesis is not all that satisfactory the expert will assess the rating on the basis of how well it is tolerated and how effective it is. The rating may not be higher than for amputation of the whole limb.b) Ankylosis and stiffness1) HipFlexion : 90° allows most actions of everyday living; 70° allows the patient to sit and negotiate stairs; 30° allows him to walk.Abduction : 20° allows virtually all actions of everyday living.Adduction : of minimal practical importance.External rotation: only the first 30° range is useful.Internal rotation: 10° is enough for most actions of everyday living.Extension : 20° is used in walking and negotiating stairs.Pain is an essential factor determining use of the hip in everyday life (walking and standing): the suggested ratings take account of this.-  AnkylosisHip in good position | 30% |-  StiffnessExtreme stiffness of several movementswith accompanying signs (radiological signs, amyotrophy, etc.), this is a more severe condition than ankylosis | up to 40% |Assuming full movement otherwiseTotal loss of flexion | 17% |Flexion limited to 30° limited to 70° limited to 90° | 13% 7% 4% |Total loss of extension | 2% |Permanent irreducible flexion of 20° | 4% |Total loss of abduction | 6% |Total loss of adduction | 1% |Total loss of external rotation | 3% |Total loss of internal rotation | 1% |2) KneeFlexion : 90° allows half and, above all, the most important actions of everyday living (walking, sitting down, using stairs); 110° allows 3/4 of everyday actions and 135° allows all of them.Extension : an extension deficit of less than 10° is compatible with 3/4 of everyday actions.-  AnkylosisKnee in good position | 25% |-  StiffnessFlexion limited to 30° limited to 50° limited to 70° limited to 90° limited to 110° | 20% 15% 10% 5% 2% |Extension deficit less than 10° 10° 15° 20° 30° | 0% 3% 5% 10% 20% |-  Laxity (no prosthesis fitted)Lateral less than 10° more than 10° | 0 to 5% 5 to 10% |Anterior isolated rotational | 2 to 5% 5 to 10% |Posterior isolated rotational | 3 to 7% 7 to 12% |Complex rotational | 10 to 17% |-  Axial deviationGenu valgum less than 10° 10 to 20° more than 20° | 0 to 3% 3 to 10% 10 to 20% |Genu varum less than 10° 10 to 20° more than 20° | 0 to 4% 4 to 10% 10 to 20% |-  Femoropatellar syndromesFemoropatellar syndromes | 0 to 8% |-  Sequelae of meniscus lesionsSequelae of meniscus lesions | 0 to 5% |3) Ankle and foot-  Tibiotalar jointWith 20° plantar flexion one can perform over half the actions of everyday living; with 35° one can perform all of them.With 10° dorsiflexion one can perform virtually all everyday actions.Loss of a few degrees of dorsiflexion is more of a handicap than an equivalent loss of plantar flexion given the restricted range of dorsiflexion.-  AnkylosisIn functional position with forefoot supple | 10% |-  StiffnessTotal loss of plantar flexion | 5% |Total loss of dorsiflexion | 5% |Plantar flexion from 0 to 10° from 0 to 20° from 0 to 30° | 5% 4% 2% |Dorsiflexion from 0 to 5° from 0 to 10° from 0 to 15° | 5% 3% 1% |Irreducible talipes equinus | up to15 % |-  LaxityLaxity | 2 to 6% |-  Subtalar jointValgus : with 5° one can perform virtually all actions of everyday living;Varus : with 5° one can perform over half the actions of everyday living and with 15° one can perform all of them.Loss of varus carries a higher disability rating than loss of valgus because varus ankylosis is less well tolerated than valgus ankylosis.-  Ankylosisin good position varus valgus | 7% 9% 8% |-  StiffnessLimitation by half | 3% |Limitation by one third | 2% |-  Midtarsal joint (Chopart’s joint) and tarsometatarsal joint (Lisfranc’s joint)-  AnkylosisMidtarsal (Chopart) | 2% |Tarsometatarsal (Lisfranc) | 4% |-  StiffnessLimitation by half | 3% |-  Metatarsophalangeal joints - toes-  AnkylosisMetatarsophalangeal of the big toe, depending on position | 2 to 3% |Ankylosis of toes 2 to 5, in good position | 0 to 2% |-  StiffnessThe expert will set the rating for stiffness on the basis of the suggested ratings for ankylosis.4) Combined ankylosisCombined ankylosis tibiotalar and subtalar joints, midtarsal joint and forefoot supple tibiotalar and subtalar joints with reduced mobility of the midtarsal joint and forefoot subtalar and midtarsal joints in good position, other joints free tibiotalar, subtalar and midtarsal joints, forefoot supple tibiotalar, subtalar, midtarsal and tarsometatarsal joints idem with ankylosis of the toes | 17% 20% 9% 19% 23% 25% |-  5) Uncompensated shorteningUp to 5 cm | 8% |Up to 4 cm | 6% |Up to 2 cm | 2% |Up to 1 cm | 0% |D) SPINESituations not described are assessed by comparison with clinical situations which are described and quantified.87.  a) Cervical spine1) Without neurological complication-  Without documented lesions of bones, discs or ligamentsIntermittent pain triggered by precise causes which are always the same, requiring pain relieving and/or anti-inflammatory drugs on demand, with minimal reduction of movement | up to 3% |-  With documented lesions of bones, discs or ligamentsVery frequent pain with permanent functional impairment requiring caution in all movements, established vertigo and associated posterior headache, with multi-stage, very extreme stiffness, depending on number of levels some remaining neck movement | 15 to 25% 10 to 15% |Frequent pain with clinically confirmed limitation of the range of motion, real but intermittent need for drug treatment | 3 to 10% |Arthrodesis or ankylosis without accompanying symptoms, depending on number of levels | 3 to 10% |With neurological or vascular complications-  See relevant chapter (nervous system)88.  b) Thoracic spine, lumbar spine and lumbosacral junction1) Without neurological complication-  Without documented lesions of bones, discs or ligamentsIntermittent pain triggered by precise causes, requiring appropriate drug treatment on demand and the avoidance of major and/or protracted effort, associated with discrete segmental stiffness | up to 3% |-  With documented lesions of bones, discs or ligamentsThoracic spine: active stiffness and pain in all movements and in all positions, requiring regular drug treatment permanent discomfort with pain between the shoulderblades, problems with weight-bearing capacity, hollow back, loss of radiological thoracic kyphosis, drug treatment required | 3 to 10% 10 to 15% |Lumbar spine and thoracolumbar and lumbosacral junctions: active stiffness and discomfort or pain in all movements and in all positions, requiring regular drug treatment very frequent pain with permanent discomfort requiring caution in all movements, with major segmental stiffness in movements, clinically confirmed limitation exceptionally severe clinical and radiological findings | 3 to 10% 10 to 15% up to 25% |-  2) With neurological complicationSee relevant chapter (Neurology)89.  CoccyxCoccydynia | up to 3% |PelvisPost-fracture pain in one ischiopubic ramus | up to% |Pain and/or instability in the pubic symphysis | 2 to 5% |Pain after dislocation or fracture of the sacroiliac joint | 2 to 5% |Associated pain and instability in the pubic symphysis and sacroiliac joint without reduction in weight-bearing capacity of pelvis or gait impairment with reduction in weight-bearing capacity of pelvis and gait impairment | 5 to 8% 8 to 18% |***IV. CARDIORESPIRATORY SYSTEM |IV – CARDIORESPIRATORY SYSTEMSituations not described are assessed by comparison with clinical situations which are described and quantified.I - HEARTThe expert will refer to the classification below, which is modelled on that of the New York Heart Association (NYHA), taking account of the functional symptoms reported by the patient, his clinical examination and a range of complementary tests (ECG, Doppler, exercise tolerance test, transoesophageal echocardiography, catheterisation, etc.).Of all the technical data, the ejection fraction is the most important for objectively quantifying sequelae.The expert should also take account of the need for medical drugs and the consequent need to monitor the patient.a) Cardiological sequelaeFunctional symptoms even at rest confirmed by clinical data (effort of getting undressed, clinical examination) and paraclinical data. Major drug treatment and frequent hospitalisation required Ejection fraction < 20% | 55% + |Functional limitation on mild exertion with signs of myocardial incompetence (pulmonary oedema) or associated with peripheral vascular complications or complex arrhythmias. Serious drug treatment and close monitoring of the patient required Ejection fraction 20% to 25% | 45 to 55% |Idem with significant drug requirement and/or in the event of associated arrhythmias Ejection fraction 25% to 30% | 40 to 45% |Functional limitation hampering ordinary activity (walking quickly), clear worsening of echography or Doppler parameters. Intolerance of effort with exertional ECG abnormalities, drug treatment required. Ejection fraction 30% to 35% | 35 to 40% |Patient reports functional limitation on ordinary exertion (2 stages), confirmed by exertional ECG or the existence of signs of myocardial dysfunction. Physical exertion contraindicated, and drug treatment required with close cardiological monitoring Ejection fraction 35% to 40% | 25 to 35% |Patient reports functional limitation on patent (significant) exertion with signs of myocardial dysfunction (Doppler, catheterisation, etc.) with drug treatment and close monitoring required Ejection fraction 40% to 50% | 15 to 25% |Patient reports functional limitation on substantial exertion (sport) without signs of myocardial dysfunction or ischaemia, with drug treatment and regular monitoring required Ejection fraction 50% to 60% | 8 to 15% |No functional limitation. Good tolerance of effort; depending on the case, drug treatment and/or regular monitoring required Ejection fraction < 60% | up to 8% |b) TransplantThe possibility of a transplant takes into account the fact that these patients need serious amounts of medical drugs and especially close monitoringDepending on functional outcome and tolerance of immunosuppressants | 25 to 30 % |II) LUNGSWhatever the origin of the lung damage, assessment must be based on the degree of chronic respiratory insufficiency, measured in terms of:-  severity of breathlessness, graded by reference to Sadoul’s clinical scale of dyspnoea:STAGE OR CLASS | DESCRIPTION |1 | Dyspnoea on major exertion greater than in stage 2 |2 | Dyspnoea when walking up a gentle incline, walking quickly, or stage 1 |3 | Dyspnoea when walking normally on the level |4 | Dyspnoea when walking slowly |5 | Dyspnoea even on mild exertion |-  clinical examination performed by a lung specialist-  complementary tests already performed or requested for the purposes of the insurance claim report. These tests must be non-invasive.Examples include imaging, endoscopy, respiratory gas measurement, spirometry, lung function tests and blood tests such as FEV1/FVC, MMEF, SaO2, TLC, FVC, TLCO/AV, PaO2 , PaCO2 :FVC : forced vital capacity; TLC : total lung capacity; FEV 1 : forced expiratory volume in 1 second; MMEF : maximum mid-expiratory flow; PaO 2 : arterial oxygen tension; PaCO 2 : arterial carbon dioxide tension; SaO 2 : arterial haemoglobin oxygen saturation; TLCO/AV : carbon monoxide transfer factor/alveolar volume.90.  Anatomical loss of all or part of a lungTotal loss | 15% |Loss of one lobe | 5% |These ratings may be added together with the disability ratings for any associated respiratory insufficiency.91.  Chronic respiratory insufficiencyDyspnoea on the slightest exertion (getting undressed) with either FVC or TLC less than 50% or FEV1 less than 40% or resting hypoxaemia (PaO2) less than 60 mm Hg, with or without hypercapnoea (PaCo2), possibly necessitating lengthy oxygen therapy (< 16 h/day) or tracheotomy or intermittent mechanical ventilation | 50% + |Dyspnoea whilst walking on the level to one’s own pace, with either FVC or TLC between 50 and 60% or FEV1 between 40 and 60% or resting hypoxaemia (PaO2) between 60 and 70 mm Hg | 30 to 50% |Dyspnoea whilst walking normally on the level, with either FVC or TLC between 60 and 70% or FEV1 between 60 and 70% or TLCO/AV less than 60% | 15 to 30% |Dyspnoea whilst walking quickly upstairs or up a gentle incline, with either FVC or TLC between 70 and 80% or FEV1 between 70 and 80% or TLCO/AV between 60 and 70% | 5 to 15% |Dyspnoea on major exertion with minor deterioration of lung function test scores | 2 to 5% |92.  Persistent painful sequelae of thoracotomy up to 5%V. VASCULAR SYSTEM |V – VASCULAR SYSTEMSituations not described are assessed by comparison with clinical situations which are described and quantified.Sequelae affecting arteries, veins and lymph vesselsThe rating will take account of any need for medical drugs and/or medical monitoring, e.g. in the case of a prosthesis which does not in itself justify a disability rating.a) ArteriesLower limb Discomfort on exertion (established intermittent claudication) Discomfort at rest (established spontaneous ischaemic pain) Idem with tissue necrosis which may be serious enough to warrant amputation | 5 to 15% 15 to 25% 25% + |Upper limb Depending on functional impairment (e.g. loss of strength, hypothermia, etc.) | 5 to 10% |-  b) VeinsSequelae of manifest phlebitis, which must be assessed bearing in mind any pre-existing conditionDiscomfort on walking for any length of time, permanent measurable oedema requiring the patient to wear support stockings at all times; recurrent stasis dermatitis and ulcers | 10 to 15% |Discomfort on walking for any length of time, permanent measurable oedema requiring the patient to wear support stockings at all times; stasis dermatitis | 4 to 10% |Feeling of ‘heavy leg’ with verifiable oedema in the evenings | up to 4% |93.  Lymph vessels ( lymphoedema)Upper limb | up to 10% |Lower limb | see Veins above |Total splenectomyDrug treatment strictly required | 15% |Asymptomatic | 5% |***VI. DIGESTIVE SYSTEM |DIGESTIVE SYSTEMSituations not described are assessed by comparison with clinical situations which are described and quantified.A) PERMANENT CUTANEOUS OSTOMIES AND TOTAL INCONTINENCE94.  a) Ostomies with pouching systemColostomy, ileostomy | 30% |b) Faecal incontinenceUncontrollable | 45% |B) PROBLEMS COMMON TO VARIOUS IMPAIRMENTS OF THE DIGESTIVE SYSTEMThe rating includes that inherent in loss of the organ.Full-blown malabsorption syndrome | 60% |Necessitating frequent medical check-ups, constant treatment and adherence to a strict diet, with effects on the patient’s general health | 30% |Necessitating regular medical check-ups, virtually permanent treatment and adherence to a strict diet, with implications for the patient’s social life | 20% |Necessitating periodic medical check-ups, intermittent treatment and dietary precautions, without effects on the patient’s general health | 10% |C) HEPATITISa) Without cirrhosisRatings are based on the Metavir score which has the virtue of having been designed specifically for hepatitis.This is based on 2 parameters, the activity score and the fibrosis score:Activity score | Fibrosis score |A0 : none A1 : minimal A2 : moderate A3 : marked | F0 : no fibrosis F1 : fibrosis, expansion of portal tracts without septa formation F2 : enlargement of portal tracts with rare septa formation F3 : numerous septa without cirrhosis F4 : cirrhosis |The ratings proposed are thus as follows:Persistent (chronic active) hepatitis | 20% |Metavir score higher than A1 F1, lower than F4 | 10% |Metavir score A1 F1 or lower | 5% |b) With cirrhosis (i.e. Metavir score higher than F4)Ratings are based on the Child-Pugh scoring system:Group | A | B | C |Serum bilirubin ((mol/l) | < 34.2 | 34.2 to 51.3 | < 51.3 |Serum albumin (g/l) | < 35 | 30 to 35 | < 30 |Ascites | Absent | Medically controlled | Poorly controlled |Neurological symptoms | Absent | Transient or mild | Hepatic coma |Nutritional status | Excellent | Good | Mediocre, loss of muscle mass |The ratings proposed are as follows:Class 3 : advanced hepatic insufficiency Child-Pugh C | 70% + |Class 2 : Child-Pugh B | 40% |Class 1 : Child-Pugh A | 20% |VII. URINARY SYSTEM |VII - URINARY SYSTEMSituations not described are assessed by comparison with clinical situations which are described and quantified.a) Loss of a kidney, not replaced, renal function normal or as beforeRating for loss of an internal organ, against the specific psychological and cultural background of the case | 15% |b) Renal insufficiencyCreatinine clearance less than 10 ml/min. Need for dialysis at a dialysis centre or at home; depending on complications | 35 to 65% |Creatinine clearance between 10 and 30 ml/min. Deterioration in general health. Very strict diet and serious drug treatment required | 25 to 35% |Creatinine clearance between 30 and 60 ml/min. Minimum BP less than 12. Asthenia, need for strict diet and medical treatment | 15 to 25% |Creatinine clearance between 60 and 80 ml/min with BP 16/9 or less, depending on diet, deterioration in general health and treatments | 5 to 15% |In the specific case where renal function has worsened in a patient who has lost one kidney, the rating for the anatomical loss may not be added, but the minimum proposed rating for deterioration in kidney function is 15%.c) TransplantationDepending on tolerance to treatment with corticosteroids and immunodepressants | 10 to 20% |If there is also renal insufficiency which is imputable, refer to the table above |d) IncontinenceUncontrollable | 30% |95.  OstomyWith pouching system | 15% |***VIII. REPRODUCTIVE SYSTEM |VIII – REPRODUCTIVE SYSTEMSituations not described are assessed by comparison with clinical situations which are described and quantified.Ratings do not take account of any endocrine effects.They do not include repercussions on sexual differentiation where the damage is sustained before puberty.Some of these ratings reflect sociocultural attitudes to loss of the organ concerned.96.  FEMALES97.  Organ lossHysterectomy | 6% |Ovariectomy bilateral unilateral | 12% 6% |Mastectomy bilateral unilateral | 25% 10% |98.  SterilityDefinitive inability of all medical methods of intervention to assist procreation in a previously fertile subject; rating includes loss of organs | 25% |99.  MALES100.  Organ lossOrchidectomy bilateral unilateral | 15% 6% |Loss of the penis | 40% |101.  SterilityIn a previously fertile subject, the rating includes loss of the testicles | 25% |If the penis is also lost, the combined rating for organ loss and sterility is 45%.***IX. ENDOCRINE SYSTEM |IX. ENDOCRINE SYSTEMSituations not described are assessed by comparison with clinical situations which are described and quantified.Problems of imputability in this area are some of the most difficult. It is extremely rare, in the work of assessment, to see physical damage represented solely by an isolated endocrine deficit.Here more than in any of the other chapters, decisions must be reached on the basis of clinical examinations and complementary tests done by a specialist.Assessment will be based on suitability for treatment, monitoring of treatment and the efficacy of treatment.a) Pituitary glandPanhypopituitarism (represented by total functional deficit of the anterior and posterior pituitary), necessitating replacement therapy and regular clinical and biological monitoring, depending on the efficacy of treatment | 20 to 45% |Diabetes insipidus, assessed in terms of the efficacy of medical drugs in controlling polyuria | 5 to 20% |b) Thyroid glandHyperthyroidism, with deterioration in biological constants, tremor, exophthalmos without effects on vision. Idem, with repercussions on other organs and/or functions | 5 to 8% 8 to 30% |Hypothyroidism (exceptional after trauma) | up to 5% |c) Parathyroid glandsHypoactive parathyroid gland, depends essentially on abnormal biomeasurements (blood calcium, blood phosphorus, parathyroid hormone) and the discomfort caused by persistent clinical signs | 5 to 15% |d) Pancreas – DiabetesNon-insulin-dependent diabetes This is never a direct result of trauma. Where imputability is established, depends on the nature of the clinical signs, need for monitoring and treatment | 5 to 10% |Insulin-dependent diabetes Onset of this type of diabetes often poses problems of imputability, except where it is the result of major pancreatic lesions. The rating will be assessed in terms of the stability of the condition, its effects on the patient’s social life and the need for medical drugs and monitoring - Poorly controlled diabetes, with malaise and repercussions for general health, necessitating close biological monitoring - Well controlled diabetes using simple insulin treatment, depending on the need for monitoring In the event of complications which leave permanent sequelae, refer to the specialist areas concerned. | 20 to 40% 15 to 20% |102.  Adrenal cortexInsufficiency of the adrenal cortex: depends on the need for drug treatment and monitoring | 10 to 25% |103.  GonadsDepends on the outcome of replacement therapy | 10 to 25% |***X. SKIN |X. DEEP BURNS OR PATHOLOGICAL SCARRINGSituations not described are assessed by comparison with clinical situations which are described and quantified.The ratings suggested essentially take account of sequelae affecting the skin and do not include aesthetic consequences and restrictions on movement.Depending on the percentage of the body surface affected by the lesionsLess than 10% | 5% |10 to 20% | 10% |20 to 60% | 10 to 25% |More than 60% | 25 to 50% |***ANNEX B PRACTICAL RULES FOR THE USE OF THE EUROPEAN DISABILITIES RATING SCALEPrinciplesThe assessing doctor is to quantify disabilities, i.e. physical or mental impairments which can be detected medically and are therefore measurable, by reference to the European scale.Some types of sequela (e.g. ophthalmological, ENT, stomatological, etc.) will require recourse to a specialist in the appropriate field. The specialist’s report must provide the assessing doctor with all the necessary technical data and considerations which will enable him to draw a conclusion on attributing and quantifying the sequelae.Regardless of the function involved (locomotion, hearing, sight, etc.), if a prosthesis, orthosis or technical aid supplied to patients improves their functional problems, assessment of those problems must take account of such benefits.DefinitionsFor the purposes of applying the European scale, permanent disability is defined as:irreversible reduction on physical and/or medical potential as detected by medical means or explicable in medical terms, added to which are the pain and mental consequences known by the doctor to be normally associated with the sequela and the impact on everyday life customarily and objectively associated with that sequela.The degree of disability is:the degree of difficulty, in relation to a theoretical maximum of 100%, experienced by any patient whose sequelae are thus quantified, in performing the normal movements and acts of everyday life.GeneralThe degrees proposed for the scale should relate to the individual as a whole. The degree should not therefore quantify a loss of function or of an organ in relation to physical integrity, rated at 0%, of that function or organ.The degrees concern sequelae assessed in isolation.Total loss of function is deemed equivalent to loss of the limb or organ in question.Situations not described are to be assessed by comparison and analogy with described and quantified sequelae.Mandatory nature of the scaleApplication of the European scale is mandatory.It is binding where it sets a predetermined degree; where it sets a range the expert must stay within the minimum and maximum degrees.Partial anatomical and/or functional sequelae must be assessed on the basis of the loss observed, taking account of the scale’s degree for total loss, in cases where the scale does not set precise degrees.Also mandatory are the rules set out for using certain sections of the scale (for example, to calculate the synergy of the fingers of one hand).For a left-handed person, the degrees applied to the right upper limb are to be applied to the left limb, and vice versa.Multiple sequelaeIn the event of multiple sequelae deriving from one accident, calculation of the overall degree is by simple addition,-  without exceeding the degree for total loss of the limb or organ in the event of multiple lesions of that limb or organ;-  without exceeding 100%.Special casesPolymorphic symptomsFor example, the scale does not provide a degree for a laryngectomy: the assessing doctor must make an overall quantification of the impact on everyday life of dyspnoea and aphonia or dysphonia (there is a degree in the scale for each of these sequelae).Pre-existing conditionsA pre-existing condition is defined as an established condition which prior to the accident caused a clinical condition which was perceptible in the everyday life of the patient.Latent pre-existing condition or predispositionA latent pre-existing condition without a perceptible clinical effect or impact on the everyday life of the patient is deemed equivalent to a pathological predisposition or susceptibility.In either case the patient is deemed not to have possessed a pre-existing condition and no subtraction may be effected from the final assessment.ANNEX C ASSESSMENT TABLE Additional allowance - Article 13Definition | Very slight | Slight | Moderate | Medium | Relatively severe | Severe | Very severe |Numbered scale | 1 | 2 | 3 | 4 | 5 | 6 | 7 |Degree for the additional allowance | 0.5% | 1% | 1.5% | 2% | 2.5% | 4% | 7% |(1) Each Institution of the Communities has adopted for itself the following rules: Council: 22 November 1976 Economic and Social Committee: 5 October 1976 Parliament: 27 January1977 Commission: 18 April 1975 Court of Justice: 9 July 1975(2) OJ L 56, 4.03.1968, p. 1.(3) OJ L XXX, XXXX.2004, p. XX.(4) These rules have been adopted by all the Institutions. Their agreement was recorded by the President of the Court of Justice on XXXX 2004.(5) OJ L 238, 25.9.2003 p. 28.[pic][pic]