Judgment No. 4473
Decision
The complaint is dismissed.
Summary
The complainant contests the decision not to recognise his son’s condition as a “serious illness” within the meaning of the provisions governing reimbursement of medical expenses.
Judgment keywords
Keywords
dependent child; illness; insurance benefits; motivation; complaint dismissed; motivation of final decision; health insurance
Consideration 13
Extract:
[I]t should be pointed out that, in Judgment 3994, the Tribunal recalls that, according to consistent precedent, it may not replace the medical findings of medical experts with its own assessment. In that judgment, the Tribunal clarifies that, although it does have full competence to say whether there was due process and to examine the medical reports on which an administrative decision is based, its role concerns situations in which a material mistake or inconsistency, a failure to consider some essential fact or a plain misreading of the evidence can be demonstrated. Moreover, in consideration 6, the Tribunal states:
“The complainant has produced no evidence in support of her claims that challenges either the lawfulness of the procedure followed during that expert assessment or the soundness of the expert’s conclusions.”
Reference(s)
Jugement(s) TAOIT: 3994
Keywords
medical opinion; role of the tribunal
Consideration 2
Extract:
The Tribunal notes that Article 35(2) [of Rule of Application No. 10] provides that a failure to observe the two-month time limit afforded to the Committee to issue its opinion, which allows the Director General to take a decision without having received that opinion, does not in itself render the decision on the internal complaint unlawful.
Keywords
internal appeals body; interpretation of rules
Considerations 4-5
Extract:
The Tribunal observes that of the eight-member Committee, four were in favour of dismissing the internal complaint. In this respect, the Tribunal refers to Judgment 4281, consideration 11, which states, in a situation where two opinions enjoyed equal support as in this case:
“In stating, in the decision of 13 December 2016, that he ‘share[d] the opinion of [those members]’, the Director General endorsed their reasoning. The plea alleging a failure to state reasons is therefore unfounded.”
Thus, the impugned decision of 21 February 2019 not only endorses the findings of the four members of the Committee who opposed the recognition of serious illness, but also provides further justification for the choice to accept the negative opinion and specifies the reasons for the complainant’s internal complaint being dismissed.
Keywords
report of the internal appeals body; motivation of final decision
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