CLAIMS AND PRESCRIPTION Instructions
117/1.5.9
Claims by the person affiliated and the Organisation under the medical and social system of the Organisation shall be prescribed in accordance with Rules 17/8 to 17/8.5.
Last update: October 2006
117/1.5.9.1 The person affiliated shall reimburse all sums unduly received. If these sums are not fully reimbursed within a reasonable period of time, the Organisation may deduct the outstanding amount from any sum due to the person affiliated or to the persons entitled under him, including sums due in the form of pension payments.
Last update: October 2006 FRAUD
Instruction 117/1.5.10
a) The Organisation may decide to suspend all or some of the benefits to a person affiliated or to one of his beneficiaries:
- in the event of suspected fraud;
- if a person affiliated or his beneficiary refuses to undergo a medical examination.
b) In the event of fraud or attempted fraud, the Organisation may decide to take one or more of the following actions:
- suspension of all or some of the benefits to a person affiliated or one of his beneficiaries;
- if the person affiliated is an official, application of disciplinary measures as provided for in Rule 21;
- if the person is affiliated on a voluntary or personal basis, definitive exclusion of that person from the medical system.
c) In the event of fraud, the person affiliated shall in addition reimburse the sums unduly received.
Last update: October 2006
87 SUBROGATION
Instructions
117/1.5.11 In accordance with Rule 17/9, the Organisation shall be subrogated to the claims and rights of action of the person affiliated against third parties, up to the amount of the benefits paid, except in the case of capital benefits, which are payable concurrently with similar compensation paid by third parties.
117/1.5.12 The person affiliated shall notify the Head of Human Resource Management of any accident to himself or another beneficiary referred to in Instruction 117/1.4.1 a), regardless whether or not such accident was caused by a third party. He shall, where appropriate, provide all information necessary to identify the persons involved and their insurers and regarding the circumstances of the accident, so as to enable the Organisation to exercise its rights vis-à-vis any third party who may be liable.
CHAPTER II - SICKNESS AND MATERNITY Section I: Health Care Expenses
Rule 17/1.6
a) The Secretary-General shall specify by Instructions what health care expenses are covered by the Organisation's medical and social system, together with the rates of cover, the exclusions and the limits applicable, according to the type of benefit, or the reason for the benefit.
b) The procedure for obtaining benefits shall be determined by the Secretary-General.
Last update: January 96
Instructions 117/1.6.1
a) In the event of sickness, maternity or accident other than those mentioned in Rule 17/1.12, the beneficiaries listed in paragraph a) of Instruction 117/1.4.1 shall be entitled to cover for expenses in respect of medical attention or surgery or of treatment or prescriptions, subject to the limits and according to the procedure laid down in Annex XIV of these Regulations. Such cover may take the form of direct payment, in full or in part, to the supplier or provider of services or of reimbursement of the person affiliated.
b) All expenses covered by sickness or maternity insurance under
the French General Social Security Scheme shall be covered by the medical and social system.
c) Beneficiaries under the Organisation's medical and social system may freely select the practitioner or establishment of their choice from among those authorised to give or prescribe care in the country or countries where their expenses are covered. In countries where chiropractors are not authorised to give or prescribe treatment, only treatment given or prescribed by chiropractors recognised by the Organisation's medical and social system shall be covered.
117/1.6.2
a) Subject to the ceilings and other conditions set out in Annex XIV, the rate of cover for health care expenses shall be 92.5% or 100% of the expenses incurred. The rate shall be specified for each type of expenditure in the tables in Annex XIV.
b) However, the rate of reimbursement shall be 100% when for health care expenses directly related to the handicap shall be 100% of the costs incurred when the beneficiary is recognised as handicapped under the legislation of his country of residence or is entitled to the allowance for a handicapped child under Regulation 16 g) of the Staff Regulations.
d) Health care expenses in respect of which a direct settlement agreement has been concluded with a service provider shall be covered 100%.
Last update: 1 July 2003
117/1.6.3 Exceptional health care expenses may be paid or reimbursed in the case of exceptional forms of treatment or long-term sickness for which the applicable limits and ceilings set out in the tables in Annex XIV are held to be inadequate after obtaining the opinion of the doctor designated by the Organisation.
Last update: Jan 96 117/1.6.4
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average monthly basis of assessment of contributions in the calendar year, the difference shall be reimbursed in full to the person affiliated who submits a request.
b) In cases where affiliation is for a period shorter than the calendar year, the average monthly basis of assessment of contributions shall be calculated in proportion to the period of affiliation. For persons affiliated who are exempt from contributions, the above amount shall be calculated with reference to Instruction 117/1.15.1 a) ii), iv) or v) as the case may be.
c) In the first quarter following the calendar year in question, the person affiliated who submits a request shall be notified by the manager of the share of health care expenses borne by him in application of the rate of cover of 92.5 %. Persons affiliated shall, on request, also be informed by the Head of Human Resource Management of the amount of the 20 % of the average monthly basis of assessment of contributions.
d) Requests for reimbursement must be sent to the manager, together with the documents referred to in the preceding paragraph, before 30 June of the following calendar year.
Last update: May 2010