UNAT Held or UNDT Pronouncements
The present case concerned the reimbursement of medical expenses incurred by a locally recruited staff member outside his duty station while travelling on private business. It was not disputed that since the Applicant was on private business at the time he fell ill, his case did not fall under any of the exceptions of sec. 6.3 of the Medical Insurance Plan (“MIP”). The Tribunal found that the MIP Rules clearly provide that only reasonable and customary expenses at the duty station are covered by the MIP and are, thus, considered as “recognized expenses” unless one of the exceptions set out in sec. 6.3 applies, which is not the case here. The out-of-pocket amount for the purpose of the stop-loss provision represents the unreimbursed portion of these recognized expenses and thus does not include expenses exceeding the reasonable and customary ones at the duty station. This provision applies to expenses that are covered by the MIP but not reimbursed in full. This is not the case for medical expenses incurred out of the duty station, for which there is a limitation in the coverage. The Tribunal thus found that the Director, DHRM, and the Controller and Director, DFAM, were correct in not applying the stop-loss provision contained in sec. 6.25 of the MIP Rules. The Tribunal noted that the Applicant was reimbursed USD16,610.49 for the medical treatment he received in Switzerland. Therefore, after a review of the documentary evidence on file, the Tribunal considered that UNHCR’s initial estimate of the reasonable and customary charges for the Applicant’s treatment, based on the information received from the American Hospital in Istanbul, was not detrimental to the Applicant. Given that the MIP Rules do not require the administering office to establish the prevailing pattern of charges based on multiple quotations, and that the Applicant did not raise any concern related to the fact that the “American Hospital” was a valid reference to establish reasonable and customary expenses at the duty station, the Tribunal found no error in the procedure that the administering office used for the establishment of recognized medical expenses. The Tribunal therefore found no discernible error in the establishment of the amount of reasonable and customary expenses at the duty station. The Applicant argued that UNHCR’s obligation to reimburse him for the totality of his medical expenses incurred in Switzerland stemmed from the attestation he was provided on 3 August 2015 to obtain a visa for his personal travel to Greece. The Tribunal noted that the source of law in this case is the MIP Rules, which are adopted through an administrative instruction and are binding upon the parties. An attestation issued by a Human Resources Officer to facilitate a visa for private travel has no legal authority to derogate from the MIP Rules. The Tribunal acknowledged that the wording of the attestation was perhaps not ideal and may have confused the Applicant. That being said, it was not such as to create any legitimate expectation that “all possible medical expenses that may occur during travel to and in any country” would be covered and reimbursed at 100 per cent under the MIP. The attestation could not be seen as a promise binding the Organization to pay for medical expenses falling outside the scope and limits of the MIP. Based on all of the above, the Tribunal found that the Applicant had not demonstrated any discernible error in the interpretation or application of the MIP Rules. The Director, DHRM, and the Controller and Director, DFAM, were bound to apply these rules, which are clear, objective and very detailed, leaving no room for administrative discretion. The MIP rules clearly define the threshold for reimbursement, the concept of reasonable and customary expenses and the methodology to properly assess them. The Tribunal concluded that the contested decision was a mere application of these rules.
Decision Contested or Judgment/Order Appealed
The Applicant contests the decision to recover USD14,707.15 in medical expenses settled in advance by the Organization.
Legal Principle(s)
N/A