In 2017 I was diagnosed with serious illness. This kind of information crushes you as if a heavy stone was put on your back. What helps in this misfortune is the fact that European institutions’ staff shouldn’t have to worry about the financial aspect of the treatment, being insured via the Joint Sickness Insurance Scheme (JSIS), staff are entitled to 100% reimbursed of medical fees where they have a recognised serious illness.
What you need to do is submit a request for the recognition of your illness as ‘serious’. Note that there are 4 criteria to meet and that what might reasonably be considered serious to the average person might not meet the JSIS criteria. Note also that the seriousness of an illness may sometimes only be possible to ascertain post surgery/intervention, yes, Schrödinger’s reimbursement!
I applied immediately, the illness was recognised as serious and I started the treatment. After 3 months, thanks to intervention of doctors and my determination, the biggest health situation was settled. Now onto healing, dealing with the the paperwork and reimbursement.
My doctor prescribed several physiotherapy sessions as a remedy to complications due to the illness and its treatment. According to General Implementing Provisions (GIPs) for the reimbursement of medical expenses, in cases of serious illness the insured person has a right to 100% reimbursement of physiotherapy sessions which are processed as ‘miscellaneous treatment’.
“The costs of the treatments listed under point 2 below, prescribed by a doctor or, in the case of psychotherapy or similar treatments, by a psychiatrist, neuropsychiatrist or neurologist, are reimbursed at the rate of 80%, up to the ceiling for each type of treatment, or 100% in the case of serious illness, up to twice the ceiling normally applied.” [bold is not present in the original](Title II Chapter 8 point 1.1., (p. 44) GIPS)
As per the rules, I send a prior authorisation request and few days later I received an answer from the PMO … informing me that my demand of physiotherapy (introduced in the case of serious illness) would be reimbursed at 80% only. PMO made even a partial copy/paste of the abovementioned quote stopping at figure 80%.
I was sure that it was a human error, just a simple mistake easy to clarify so, I used a PMO online tool dedicated to introducing complaints (which was the only way of communicating with PMO, we now have a phoneline). I received a confirmation of the request and a reference number of the ticket and that’s all.
The PMO is supposed to reply within 15 days, but my request had apparently fallen into a black hole. After 6 weeks of no answer, I wrote again via the tool asking this time for a reply to the first ticket. Two days later I received the answer for the first question, saying that the physiotherapy is reimbursed at rate of 80% without any reference to the context of wrong classification of the request which should be done “in the case of serious illness”. Like that the first ticket was been closed and so was the second. Being from an ex-communist country I had a very unpleasant feeling of being confronted by the totalitarian administration of a communist country acting like “we do whatever we please and you can do nothing to us”.
At this point I was about to give up, I was still recovering from a serious illness and the last thing I wanted was a fight with the administration, I didn’t want to waste my energy, and honestly, I didn’t have any idea of what else I could do. But then I met a friend who was a member of Generation 2004. After a very pleasant conversation about various topics, I complained about my situation with the PMO. My friend guided me through the process and in less than two hours I received an email from the Head of the Unit – Sickness Insurance (named Settlements Office Brussels back in 2017) in which firstly he expressed apologies for late reply, secondly he admitted that there was a clear misunderstanding in the comprehension of my request and thirdly he confirmed that the prior authorization for “revalidation” was accepted in the frame of the serious illness and that I was going to be reimbursed at the rate of 100%. Two days later an amended official decision followed.
There is a significant administrative burden to being sick, particularly at the Commission. You have to know what you’re entitled to, check out existing agreements with providers, ensure your paperwork complies with the rules and then meet the deadlines. You then have to decode the reimbursement account sheet.
If you have difficulties, please try to speak to a human being, the option does indeed still exist! If you can find someone who has been through something similar then please ask them questions! If you are still not making progress you always have the option of opening a formal request for a decision to be reviewed (there is a 3-month deadline for this).
While we wish you all good health, we do understand that when colleagues are already ill it can be difficult to know what the rules are and who to talk to. We’re here to help! Please don’t get stuck!
Some additional info on costs/reimbursement:
- the JSIS now openly advises all members ‘to opt for private complementary insurance to supplement the JSIS reimbursement in the event of major medical expenses (hospitalization, etc.).’ (JSIS, Practical information).
- Special reimbursement might be a possibility where ‘your medical costs have already been reimbursed, but the cumulative costs that you have had to meet yourself (usually 15% or 20%) exceed half of your average basic monthly salary (or pension) over a 12-month period.’
- Direct billing might be possible if the hospital agrees to work with the Commission directly to have the bills paid. Note that not all hospitals are happy to accept this. (e.g. one colleague’s request was refused by a private hospital in the UK in 2014 (threat to cancel surgery if not paid in full and in advance)).
- 18 month time limit:
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Life can be surprising, and life in the Commission can be surprising too. If you have encountered an eyebrow-raising situation, please share it with us!
If still possible, we will try to help otherwise, we will anonymise the events and publish the story (we are also very happy to receive stories where you overcame all obstacles: tell us how you did it!).
So, if you are tempted to share your story, please write to us with the title ‘it happened to me’!
Keep calm, take notes and write to us!
Your Generation 2004 team
