*Update 16.01.2023 if the laboratory tests are done via your GP you will be reimbursed at only 85%. If they are prescribed by the medical service they are reimbursed at 100%.* Generation 2004 is very happy to inform you of the positive outcome of an Article 90(2) complaint against the Office for the Administration and Payment of Individual Entitlements (PMO), confirming that staff are indeed entitled to 100% reimbursement of the laboratory test costs as part of the annual medical visit. As per our June article, we failed to understand why the annual medical visit at the medical service is free of charge but when staff are forced to go to an external laboratory as part of the obligatory annual medical check-up they are habitually reimbursed at the rate of only 85% and up to a fixed ceiling we already know to be below the real cost.
The facts
Our colleague was examined at the premises of the Medical Service in Brussels in autumn 2020 and promised follow-up contact by the Medical Service’s in-house laboratory to schedule the usual laboratory tests. The following month, in the absence of contact, our colleague emailed about scheduling the tests and received no response. Our colleague then followed that up with a phone call a couple of weeks later and was told that, due to the worsening COVID-19 pandemic, all in-house laboratory services in relation to the annual medical exams had been suspended for an unspecified period. In early 2021, three months later, our colleague then addressed the issue personally with the Head of the Brussels Medical Service on the day of their flu vaccination appointment and shortly received an updated laboratory prescription form from a Commission medical officer with the instruction to take the tests at an external laboratory which was done that same month.
Our colleague then requested reimbursement from the PMO via the Medical Service – Annual medical check-up function and uploaded the paperwork.
The complainant’s reimbursement request was refused by the PMO in its entirety, the corresponding Staff Contact reply stating that the reimbursement request should be resubmitted as a standard reimbursement (85%). Our colleague re-contacted the Head of the Brussels Medical Service who agreed with the PMO that this reimbursement should be re-reqeusted from Joint Sickness Insurance Scheme (JSIS) at the rate of 85%.
In other words, the PMO and the Medical Service expected the complainant to bear 15% of the costs of the laboratory tests that are part of the standard protocol for annual medical exams under Article 59(6) of the staff regulations.
Out colleague then asked the Commission’s Mediation Service to intervene. However, the Mediation Service informed the complainant that they were unable to help because of staff changes in the PMO and a lack of responsiveness from the PMO and the Medical Service.
Having exhausted all the established means to query the outcome, our colleague lodged a complaint under Article 90(2) of the Staff Regulations against the PMO refusal to reimburse at 100% rate the laboratory tests costs as part of the annual medical visit.
The law
Article 59(6) of the Staff Regulations provides as follows:
‘6. Officials shall undergo a medical check-up every year either by the institution’s medical officer or by a medical practitioner chosen by them.
In the latter case, the practitioner’s fees shall be payable by the institution up to a maximum amount fixed for a period of no more than three years by the Appointing Authority after consulting the Staff Regulations Committee.’
The Commission has adopted implementing rules as regards the reimbursement claims for medical treatments contained in Administrative Notices N° 45-2014 and N° 46-2014 of 09/12/2014.
Administrative Notice N° 46-2014 of 09/12/2014 stipulates as follows:
‘Reimbursement of fees for a consultation with a doctor as part of the annual medical visit
- From 1 January 2015, the former ‘pink forms’ will be replaced by a ‘consultation form for a medical visit’.
- You pay the doctor directly for the consultation.
- Reimbursement will be covered by the PMO. The principle of a free annual medical visit is, of course, maintained (i.e. 100% of expenses will be reimbursed[1]).
- In order to be reimbursed, you should send to the PMO, via the application ‘JSIS-online’ only:
- written proof of the visit, including as minimum requirements the patient’s full name, the nature of the treatment, the dates and fees paid for each medical treatment and the name and official references of the healthcare provider. Please note that as of 1 January 2015 reimbursement claims for medical treatments by doctors and healthcare providers in Belgium recognised by INAMI/RIZIV need to be accompanied by the official forms required under Belgian law for reimbursements of medical expenses by insuring organisations (i.e. ‘mutuelles/mutualiteiten’) under the mandatory healthcare and indemnity insurance (attestation de soins donnés/Getuigschrift voor verstrekte hulp). See Administrative Notice 45/2014 for more details,
- the medical prescription given by the Medical Service (‘consultation form for a medical visit’) duly completed by you and the doctor should also be included.
- Additional examinations not covered by the prescription given by the Medical Service but proposed by the specialist can be reimbursed by the JSIS according to the normal rules and limits (i.e. in principle no reimbursement at 100%). They must, however, be declared on the basis of a separate invoice in a separate request for reimbursement.
Footnotes
[1] In the particular case that you opt for not having the general medical examination done by the Medical Service but by a general practitioner of your choice, the reimbursement for this examination remains limited to the set ceiling.’
The decision
In October 2021, DG Human Resources and Security (HR) communicated to the complainant its decision on his complaint under Article 90(2) of the Staff Regulations.
With this decision, DG HR decided to uphold the complaint and to annul the contested decision of the PMO refusing the reimbursement at 100% of the costs for laboratory tests, prescribed by the Medical Service, as part of the annual medical visit under Article 59(6) of the Staff Regulations.
The follow-up
In accordance with DG HR’s decision, the PMO has now reimbursed our colleague 100% of the laboratory costs. We will continue to closely monitor this case to make sure that any other eligible staff member – is reimbursed at 100% for the costs of laboratory tests as part of the annual medical visit, if the Medical Service’s in-house laboratory is unable to carry them out.
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