COMMON RULES on the insurance of officials of the European Communities against the risk of accident and of occupational disease

Article 1 Subject

These rules lay down, pursuant to Article 73 of the Staff Regulations, 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 Accident

1. 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. 2. The following shall inter alia be considered accidents:

- poisoning, - infections, sicknesses and injuries and any other consequences of the bites of animals or of the stings of insects, - sprains, tears or lacerations and ruptures of muscles or tendons caused by exertion, - 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 diseases

1. The diseases contained in the "European schedule of occupational diseases" annexed to the Commission Recommendation of 19 September 2003 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. 2. Any disease or aggravation of a pre-existing disease not included in the schedule 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 cover

1. Accidents shall not be covered by Article 73 of the Staff Regulations if they are due to the following causes:

(a) subject to paragraph 3, wilful involvement of the insured party in a brawl; (b) manifestly reckless acts committed by the insured party or his/her participation by means of motorised equipment in sporting contests, races and official trials; (c) 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; (d) the use by the insured party of drugs not prescribed by a doctor, except in case of error; (e) the deliberate handling by the insured party of military arms or ammunition, except in an emergency; (f) practice of the following sports regarded as dangerous: boxing; karate; parachuting; paragliding; bungee jumping; speleology; underwater fishing and exploration with breathing equipment including containers for the supply of air or oxygen; climbing cliffs or pinnacles of rock or mountain peaks otherwise than on beaten tracks, except in an emergency, and subject to paragraph 2; (g) a criminally punishable wilful act which has been the subject of a final sentence to immediate imprisonment. If that sentence was passed in a third country, the exclusion from cover shall apply only if the judicial proceedings guaranteed the fundamental rights of defence and if the same act had been punishable by imprisonment under the law of the state of which the insured party is a national.
2. The exclusions referred to in paragraph 1 must be directly related to the aggravation of the risk(s) they cause. 3. 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, when the insured party is called to account and placed in a position of self defence, unless they are the inexcusable fault of the insured party.

Article 5 Suspension of cover

Insurance 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.

Article 6 Deduction of benefits

If an insured party suffers 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 benefits

1. 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. 2. The following shall, however, be regarded as accidents within the meaning of these rules:

– suicide; – bodily or mental injuries sustained in an emergency or in self-defence or when saving human life or salvaging property; – 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 party participated of his/her own free will in the violent action in which he/she was injured, other than in self-defence.

Article 8 Subrogation

Insured 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 responsible, 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 responsible, the insured parties or those entitled under them shall obtain the consent of the institution to which the insured party belongs.

CHAPTER II - BENEFITS

Article 9 Reimbursement of expenses

1. Insured parties who suffer 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 first and second 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. 2. 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 sum

1. 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 fourth indent 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. 2. 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 invalidity

Article 12 Annuity

Where 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 allowance

Article 14 Flat-rate allowance

Where, 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.

CHAPTER III PROCEDURE

Article 15 Accident report

1. 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. 2. 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. 3. The administration may hold an inquiry.

Article 16Statement of occupational disease

1. 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) of the Staff Regulations 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. For insured parties no longer in active service at the institutions, benefits shall be calculated on the basis of salary during the final year of active service. That salary shall be updated as at the date taken into account in the third subparagraph. 2. 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 by the Administration 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 opinion

The Administration may obtain any expert medical opinion necessary for the implementation of these rules. Failure by the insured party 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 Decisions

Decisions recognising the accidental cause of an occurrence, be it an occurrence attributed to occupational or non-occupational risks, and decisions linked thereto, recognising the occupational nature of a disease or 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 injuries

1. Insured parties shall be required to inform the Administration of any change in their state of health by submitting medical certificates. 2. If insured parties provide no information under paragraph 1 of this Article 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. 3. 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. 4. 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. 5. 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 Committee

1. 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. 2. 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. 3. 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 case

Insured 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 Committee

1. The Medical Committee shall consist of three doctors:
– one appointed by the insured party or those entitled under him/her; – one appointed by the appointing authority; – 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 must have expertise in assessing and treating bodily injury. 2. The institution shall define the terms of reference provided to the Medical Committee. 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). The fees and expenses of the doctors making up the Medical Committee shall be set in accordance with a scale laid down by the Community institutions' Heads of Administration, depending on the complexity of the case assigned to the Medical Committee. Before confirming the terms of reference given to the Medical Committee, 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 or those entitled under him/her shall be free at all times to discontinue the procedure for referral to the Medical Committee. In that case, the fees and expenses of the doctor chosen by the insured party or those entitled under him/her and half of the fee and 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. 3. 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. 4. 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. 5. 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 paragraphs 1 to 4 may be borne by the institution.

Article 23 Consulting another doctor

1. 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 first subparagraph shall be communicated by the appointing authority to the insured party or those entitled under him/her. 2. 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 Confidentiality

Staff 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 73

Recognition 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 BENEFITS

Article 26 Settlement of claims

Any 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 benefits

The lump sums referred to in Articles 10 and 11 and the annuity referred to in Article 12 shall be paid in euro.

CHAPTER V APPEALS

Article 28 Appeal

Decisions 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.

CHAPTER VI FINAL PROVISIONS

Article 29 Regular concertation

The Staff Regulations Committee shall consider the application of these rules at regular intervals.

Article 30 Repeal

The 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 January 2006, save where a case is re-opened under Article 21.

Article 31 Entry into force