Staff regulations - Appendix XII: Regulations on the medical and social insurance scheme

Subject to the provisions of Article 43, paragraph 4, of the Staff Regulations, the staff members referred to in Article 1, paragraph 1, of the Staff Regulations shall be affiliated to the Organisation’s Medical and Social Insurance Scheme.

Article 2 – Commencement and cessation of entitlement

1. Entitlement to the medical benefits and accident insurance cover provided by the Organisation’s Medical and Social Insurance Scheme shall start on the date on which the staff member’s journey to take up his/her duties begins.

Entitlement to the other benefits provided by the Scheme shall start on the date on which the staff member takes up his/her duties, and shall be conditional on his/her having undergone the medical examination for new recruits.

2. Except in cases where maintenance of rights is provided for in these Regulations, entitlement to the benefits provided for in Part I of these Regulations shall cease on the date on which the staff member’s contract with the Organisation terminates (Article 23 of the Staff Regulations).

However, staff members in receipt of the expatriation or residence allowance shall remain affiliated to the Organisation’s Medical and Social Insurance Scheme for two weeks after termination of their contract.

Benefits shall cease after that date, subject, in the case of previously occurring contingencies, to rights acquired on the conditions applying to each contingency.

Article 3 – Suspension of entitlement

1. Unless otherwise provided for in the special rules governing maintenance of rights, entitlement to the benefits provided by the Organisation’s Medical and Social Insurance Scheme shall be suspended throughout periods of unpaid leave (Appendix VII to the Staff Regulations).

2. The Secretary General shall determine by rule the conditions for voluntary affiliation to the Organisation’s Medical and Social Insurance Scheme during periods of unpaid leave.

Article 4 – Definition of benefits and risks covered – Interpretation

1. The Secretary General shall determine by rule the nature of the expenses covered by the Organisation’s Medical and Social Insurance Scheme, and also the rates of cover, exceptions and restrictions which apply, depending on the nature or cause of the benefits.

2. If doubts or disputes arise concerning application of the Regulations on the Organisation’s Medical and Social Insurance Scheme, reference shall be made to the French Social Security legislation in force at the time when the event giving rise to a claim for benefits occurs.

3. The text of insurance policies taken out by the Organisation relating to cover for health care expenses or provident cover shall be made available to staff members.

Article 5 – Maintenance of rights

1. When their contract with the Organisation terminates for one of the reasons specified in Article 23, paragraphs 2 and 3 a. and b. of the Staff Regulations, staff members affiliated to the Organisation’s Medical and Social Insurance Scheme shall continue to be covered in respect of health care expenses for a period equivalent to that provided for under the French Social Security Scheme if, having taken up a new professional activity, they are not covered for such expenses by another scheme, either because illness or pregnancy pre‑dates their joining that scheme or because entitlement thereunder is subject to a qualifying period, or if they have not taken up a new professional activity.

In such cases, cover of health care expenses shall be limited to the amounts refundable under the local rules of the French Social Security Scheme in Alsace-Moselle.

2. In the cases provided for in paragraph 1, health care expenses shall be covered on the same conditions for persons entitled through staff members, as defined in French Social Security legislation.

3. Provided that their health care expenses cannot be covered by a compulsory social security scheme, former spouses of staff members affiliated to the Organisation’s Medical and Social Insurance Scheme shall continue to be covered in respect of health care expenses under the latter scheme for a period following divorce equivalent to that provided for under the French Social Security Scheme. In such cases, cover shall be limited to the amounts refundable under the local rules of the French Social Security Scheme in Alsace-Moselle.

4. Persons entitled through staff members who die while serving, who are not covered by a social protection scheme either in respect of a professional activity, or by virtue of a pension scheme, shall continue to be covered in respect of health care expenses for a period of one year. In such cases, cover shall be limited to the amounts refundable under the local rules of the French Social Security Scheme in Alsace-Moselle.

5. During periods of unpaid leave, entitlement in respect of health care expenses shall be maintained during the period provided for in the French Social Security Scheme. The cover shall be limited to the amounts refundable under the local rules of the French Social Security Scheme in Alsace-Moselle.

6. The provisions of this Article shall not apply to the persons in receipt of pensions under the Organisation’s Pension Scheme, referred to in Article 16, paragraph 1, of these Regulations.

Article 6 – Exceptions

1. Life insurance benefits shall be guaranteed for all deaths, even those resulting from an industrial disease covered by French Social Security legislation.

However, the following risks shall be covered with certain reservations:

- if a staff member deliberately commits suicide in full awareness of what he/she is doing, cover shall apply only if he/she has been affiliated to the Organisation’s Medical and Social Insurance Scheme for at least one year. If, however, the beneficiaries can show that the staff member in question was unaware of what he/she was doing when he/she committed suicide, cover shall apply with no qualifying period;

- in wartime, life insurance cover shall be subject to the conditions applying to life insurance in wartime specified in the law of the country where the staff member is serving. Permanent, total disability resulting from injuries sustained in a generalised war shall never be covered.

2. The following shall also not be covered:

a. illnesses or accidents deliberately induced or caused by beneficiaries or persons entitled through them;

b. war injuries sustained while beneficiaries are serving in the armed forces, either as conscripts or volunteers;

c. injuries or lesions sustained in the course of speed trials, competitions or wagers, other than ordinary sports competitions;

d. injuries sustained in insurrections or riots in which beneficiaries have unlawfully taken part, or in fights, unless engaging in lawful self-defence;

e. illnesses or accidents affecting beneficiaries resident in countries which obstruct the lawful verifications which the Organisation is entitled to carry out;

f. aircraft accidents, unless the beneficiary is on board an aircraft officially certified as airworthy and flown by a pilot in possession of a current pilot’s licence. The pilot may be the beneficiary himself/herself, provided that he/she has complied with current regulations. Competitions, wagers, races, aerobatics, record attempts or preparatory tests, acceptance flights, gliding, and parachute jumps, other than those rendered necessary by an aircraft’s critical condition, shall not be covered;

g. the consequences of any attempt at self-mutilation.

Article 7 – Limitation and fraud

1. The right of affiliated persons to bring proceedings shall lapse two years from the date on which the event giving rise to a claim for benefits occurs.

2. Affiliated persons shown to have defrauded the Scheme shall be required to repay the sums wrongfully received and shall also, if they are serving staff members, be liable to disciplinary sanctions.

Article 8 – Subrogation

1. The Organisation shall be entitled to take over affiliated persons’ legal claims against potentially liable third parties, up to the level of the benefits provided. This right of subrogation shall not apply to capital benefits which may be added to similar compensation paid by third parties.

2. Affiliated persons must inform the Director of Human Resources of any accident of which they or other beneficiaries have been the victim, whether or not that accident was caused by a third party. They must furnish any information concerning the identity of the persons involved and their insurers, and also the circumstances of the accident, which the Organisation may require to pursue claims against potentially liable third parties.

CHAPTER II: BENEFITS

Article 9 – Expenses for medical treatment [2]

1. The cost of medical treatment prescribed or provided by a qualified medical practitioner in cases of accident, illness or maternity shall be covered in accordance with the rules laid down by the Secretary General.

2. Entitlement to benefits for medical treatment shall apply to staff members and persons entitled through them, viz.:

a. dependent children under the age of 20; however, supplementary cover for medical treatment may be extended, on payment of an additional contribution borne entirely by the staff member, to dependent children aged more than 20 and less than 29 who are covered by Social Security schemes in their own right (students, job-seekers, etc.);

b. spouses of staff members or persons cohabiting with staff members (as unmarried partners) who are totally dependent on them. In such cases, cover shall be limited to the amounts refundable under the local rules of the French Social Security Scheme in Alsace-Moselle. However, supplementary cover for health care costs may be extended to that person on payment of an additional contribution borne entirely by the staff member. On payment of an additional contribution borne entirely by the staff member, supplementary cover may be extended to spouses or unmarried partners who are professionally active or in receipt of unemployment benefits or retirement pensions;

c. a parent or other close relation who lives in the staff member’s home and looks after the house and at least two of his/her dependent children under the age of 14. In such cases, cover shall be limited to the amounts refundable under the local rules of the French Social Security Scheme in Alsace-Moselle. However, supplementary cover for health care costs may be extended to that person, on payment of an additional contribution borne entirely by the staff member;

d. any person, but only one, who has lived with the staff member for at least one year and is wholly dependent on him/her (proof is required). In such cases, cover shall be limited to the amounts refundable under the local rules of the French Social Security Scheme in Alsace-Moselle. However, supplementary cover for health care may be extended to that person, on payment of an additional contribution borne entirely by the staff member.

3. For the definition of persons entitled through staff members, reference shall be made to the French Social Security legislation in force when these Regulations are adopted and to any subsequent changes in such legislation.

4. Staff members must inform the Organisation of any other compulsory scheme which provides health cover for them or persons entitled through them.

5. Persons entitled to benefits provided for in this chapter, who are personally entitled to social protection under one or more other compulsory social insurance schemes, must always obtain the benefits due under those schemes before applying for benefits under the Organisation’s Medical and Social Insurance Scheme, from which the former benefits shall be deducted.

Parents who are each insured under a sickness and maternity scheme shall designate, by mutual agreement, one of them to be primarily responsible for their children in respect of claims for sickness and maternity benefits.

This designation may be made at any time. Once made, it may only be changed, by mutual agreement of the parents, after an interval of one year.

However, when one of the insured parents ceases to be entitled to sickness and maternity insurance benefits, their children shall be entitled to these benefits through the other parent.

6. In cases where specific sickness benefits which are not covered by the Organisation’s Scheme could have been provided by French Social Security, the Secretary General shall decide in each instance whether a reimbursement should be made to the staff member in question.

Article 10 – Continued payment of salary during illness

1. Under the Organisation’s Medical and Social Insurance Scheme, and subject to the special rules applying to accidents at work and to industrial diseases, staff members shall be entitled to continued payment of their salaries and allowances for the periods specified in the rules on the French Social Security scheme.

2. Continued payment of salary and allowances shall be conditional on the production of a medical certificate. Payment of salary and allowances may be suspended if the doctor appointed by the Organisation finds that the staff member is not following the treatment ordered or instructions issued by his/her own doctor, or that he/she is fit to return to work.

Article 11 – Maternity, paternity or adoption benefits

1. Serving staff members granted maternity, paternity or adoption leave shall be entitled, during such leave, to continued payment of their full salaries and allowances.

2. Staff members shall also receive a lump-sum allowance on birth or adoption of a child.

3. When both parents of the child are staff members of the Organisation, this allowance shall be paid once, to the parent designated by both.

Article 12 – Disability benefits [3]

1. In cases of total, permanent disability, recognised as such under the Organisation’s pension schemes, if the disability is regarded by the Invalidity Board provided for in those schemes as a level-three disability under the French Social Security Scheme classification, if it is confirmed that this condition renders a staff member unfit for all work, professional or other and if he/she permanently requires another person’s assistance to perform the normal actions of everyday life, then he/she shall be entitled to payment of a capital sum equivalent to two years’ salary^{^[4]}.

2. In cases of total, permanent disability, recognised as such under the Organisation’s pension schemes, if the disability is regarded by the Invalidity Board provided for in those schemes as a level-one or level-two disability under the French Social Security Scheme classification, and if it is confirmed that this condition renders a staff member unfit for all work, professional or other, then he/she shall be entitled to payment of a capital sum equivalent to one year’s salary. However, the sum paid shall decrease progressively after the age of 56. Furthermore, where a staff member’s state of health worsens in the five years after he/she is declared disabled to the extent that he/she would now be classed in category three of the French Social Security classification, the capital sum shall be increased to the level specified in paragraph 1.

3. A staff member who, either at the time of being declared disabled or subsequently, owing to a worsening of his/her condition within five years of being so declared, permanently requires the assistance of another person to perform the normal actions of everyday life, shall also receive a disability pension, payable for life.

4. In the event of permanent partial incapacity which is recognised as such by the Invalidity Board provided for under the Organisation’s pension schemes and which renders him/her unable to perform, on a full-time basis, his/her employment or any other duties corresponding to his/her experience and qualifications which may be proposed by the Organisation, a staff member shall be entitled to an annual allowance, the amount and duration of payment of which shall be determined by rule by the Secretary General.

Article 13 – Death grant[5]

If a staff member dies, a capital sum equivalent to two years’ salary^{^[6]}, shall be paid to the persons entitled through him/her, in accordance with the rules laid down by the Secretary General, unless this sum has already been paid under Article 12, paragraphs 1 or 2.

Article 14 – Accidents at work and industrial diseases

1. An accident at work is any accident which is caused by, or occurs in the course of, functions undertaken in the Organisation, and which causes physical or mental harm to a serving staff member.

In particular, any physical injury due to a sudden and usually violent external cause is regarded as accidental.

Specifically, any accident occurring while a staff member is on an official journey shall be regarded as an accident at work, unless he/she has interrupted that journey for personal reasons unconnected with his/her duties.

Accidents at work shall also include accidents occurring:

i. on a staff member’s normal journey to and from work;

ii. when a staff member is travelling to or from an official destination or performing duties connected with an official journey;

iii. on the journey preceding a staff member’s taking up his/her duties, or following his/her ceasing those duties, if that journey follows the route and respects the time limits laid down in the Organisation’s regulations.

Industrial diseases caused by functions performed for the Organisation shall count as accidents at work.

Accidents at work or industrial diseases shall include the further effects of an accident occurring, or an industrial disease contracted, while a staff member was performing his/her duties, even if these effects manifest themselves when he/she has left the Organisation.

If problems arise with interpretation of the principles laid down in paragraphs a) to e) above, French legislation on accidents at work and industrial diseases, and the relevant French case law, shall apply by analogy.

2. Any accident covered by paragraphs a., b. and c. of this Article must be notified to the Director of Human Resources within 48 hours, unless circumstances make this impossible.

3. The Secretary General shall inform the staff member, when an enquiry and any necessary medical examinations have been carried out, of the decision to recognise the accident as an accident at work, or of the reasons for any decision by the insurers not to do so.

4a. The medical costs of treating the effects of an accident at work or industrial disease, and of functional rehabilitation, shall be covered at 100% of the tariff applying in the French Social Security scheme.

b. Staff members obliged to stop work by an accident at work shall be entitled to continued payment of their full salaries and allowances, and shall, if employed on a fixed-term contract, be entitled to extension of that contract until either their health is recognised as restored or they are declared disabled or, at latest, up to the age of 65.

CHAPTER III: FUNDING

Article 15

Staff members affiliated to the Organisation’s Medical and Social Insurance Scheme pursuant to Article 1 of these Regulations shall contribute one-third of the cost of cover for benefits provided by the Scheme, with the exception of benefits for accidents at work or industrial diseases.

PART II: Affiliation of pensioners and former staff

CHAPTER I: GENERAL PROVISIONS

Article 16 – Affiliation

1. Subject to the provisions of Article 21, paragraph 3, below, the following persons shall be affiliated to the Organisation’s Medical and Social Insurance Scheme:

- former staff in receipt of retirement pensions under the Organisation’s Pension Scheme and aged at least 60;

- former staff in receipt of early retirement pensions under the Organisation’s Pension Scheme, regardless of age;

- former staff in receipt of disability pensions under the Organisation’s Pension Scheme, regardless of age;

- surviving spouses in receipt of survivors’ pensions within the meaning of, and subject to the conditions and limitations provided for in, the Organisation’s Pension Scheme;

- orphans or other dependants of staff members who die while still working or after qualifying for a disability pension or an immediate or deferred retirement pension, who are in receipt of orphans’ or other dependants’ pensions under the Organisation’s Pension Scheme Rules and Article 5 of Appendix IV to the Staff Regulations.

2. Apart from the cases expressly listed in paragraph 1, a former staff member of any age may be affiliated at his/her own expense to the Organisation’s Medical and Social Insurance Scheme, if he/she has so requested prior to expiry of his/her contract with the Organisation, under the special conditions laid down by the Secretary General.

3. Affiliation shall cease when the persons concerned cease to fulfil the conditions for affiliation.

Article 17 – Commencement and cessation of entitlement

1. In the cases listed in Article 16, paragraph 1, of this Part, entitlement to the benefits provided for in this Part shall begin on the date on which the beneficiary becomes entitled to the benefits provided by the Organisation’s Pension Scheme.

2. Entitlement to the benefits provided for in this Part shall cease, for any person in receipt of a pension, on the date on which he/she ceases to receive pension benefits.

3. In the case specified in Article 16, paragraph 2, of this Part, cover shall begin on the day following that on which the staff member’s contract terminates, and shall cease on the date on which he/she withdraws from the Scheme.

Article 18 – Suspension

Cover for medical treatment, on the conditions applying to the affiliated persons referred to in Article 16, paragraph 1, shall be suspended for former staff members in receipt of pension benefits under the Pension Scheme Rules who engage in a remunerated professional activity.

Article 19 – Definition of benefits and risks covered

The Secretary General shall determine by rule the nature of the expenses covered by the Organisation’s Medical and Social Insurance Scheme, and also the rates of cover, exceptions and restrictions which apply, depending on the nature or cause of the benefits.

If doubts or disputes arise concerning application of the Regulations on the Organisation’s Medical and Social Insurance Scheme, reference shall be made to the French Social Security legislation in force at the time when the event giving rise to a claim for benefits occurs.

The text of insurance policies taken out by the Organisation relating to cover for health care expenses or provident cover shall be made available to affiliated persons.

Article 20 – Exceptions – limitation and fraud – subrogation

Articles 6, 7 and 8 shall apply, mutatis mutandis, to Part II (pensioners and former staff).

CHAPTER II: BENEFITS

Article 21 – Expenses for medical treatment

1. The cost of medical treatment prescribed or provided by a qualified medical practitioner in cases of accident, illness or maternity shall be covered by the Organisation in accordance with the rules laid down by the Secretary General.

Entitlement to benefits for medical treatment shall apply to affiliated persons and persons entitled through them, viz.:

a. dependent children under the age of 20. However, supplementary cover for medical treatment may be extended, on payment of an additional contribution borne entirely by the staff member, to dependent children aged more than 20 and less than 29 who are covered by Social Security schemes in their own right (students, job-seekers, etc.);

b. the dependent spouses of affiliated persons or persons cohabiting with affiliated persons (as unmarried partners) and totally dependent on them. On payment of an additional contribution borne entirely by the staff member, supplementary cover may be extended to spouses or unmarried partners who are professionally active or in receipt of unemployment benefits or retirement pensions;

c. a parent or other close relation who lives in the affiliated person’s home and looks after the house and at least two of his/her dependent children below the age of 14. In such cases, cover shall be limited to the amounts refundable under the local rules of the French Social Security Scheme in Alsace-Moselle. However, supplementary cover for health care costs may be extended to that person, on payment of an additional contribution borne entirely by the staff member;

d. any person, but only one, who has lived with the affiliated person for at least one year and is wholly dependent on him/her (proof is required). In such cases, cover shall be limited to the amounts refundable under the local rules of the French Social Security Scheme in Alsace-Moselle. However, supplementary cover for health care costs may be extended to that person, on payment of an additional contribution borne entirely by the staff member.

2. For the definition of persons entitled through affiliated persons, reference shall be made to the French Social Security legislation in force when these Regulations are adopted and to any subsequent changes in that legislation.

3.a. Persons entitled to benefits provided for in this chapter, who are personally entitled to social protection under one or more other compulsory social insurance schemes, must always obtain the benefits due under those schemes before applying for benefits under the Organisation’s Medical and Social Insurance Scheme, from which the former benefits shall be deducted.

b. Nonetheless, a person entitled to a benefit provided for in this chapter who wishes to waive his/her right to protection under one or more other compulsory social schemes may do so, provided that he/she meets any and all additional costs incurred by the Organisation.

4. Parents who are each insured under a sickness and maternity scheme shall designate, by mutual agreement, one of them to be primarily responsible for their children in respect of claims for sickness and maternity benefits.

This designation may be made at any time. Once made, it may only be changed, by mutual agreement of the parents, after an interval of one year.

However, when one of the insured parents ceases to be entitled to sickness and maternity insurance benefits, their children shall be entitled to these benefits through the other parent.

Article 22 – Maternity, paternity or adoption benefits

1. Affiliated persons shall receive a lump-sum allowance on birth or adoption of a child.

2. When both parents are affiliated to the Organisation’s Medical and Social Insurance Scheme, this allowance shall be paid once, to the parent designated by both.

Article 23 – Disability or death benefits

1. Former permanent staff in receipt of retirement pensions under the Organisation’s Pension Scheme, who retire before the age of 65, may request maintenance of cover for death and for permanent and total disability.

2. The capital sum paid in the event of death, or of permanent and total disability, shall be that to which the former staff member would have been entitled on the date on which his/her duties ceased, under the rules applying to serving staff.

3. The capital sum, based on the staff member’s last salary prior to retirement, shall remain unchanged during the period of maintained entitlement.

4. The death grant shall be paid to the persons entitled, in accordance with the rules laid down by the Secretary General.

5. This cover shall terminate at age 65 in all cases.

6. Disability and death insurance cover shall not be open to the former staff members referred to in Article 16, paragraph 2.

CHAPTER III: FUNDING

Article 24

Persons affiliated to the Organisation’s Medical and Social Insurance Scheme under Article 16, paragraph 1, of these Regulations shall contribute one-third of the cost of cover for benefits provided by the Scheme.

However, in the cases specified in Article 21, paragraph 3b., they shall pay the entire cost of cover from the first euro, less the part payable by the Organisation in respect of supplementary affiliation.

The Secretary General shall determine the extent to which part of the cost of cover for the affiliated persons referred to in Article 16, paragraph 1, will be borne by the compulsory insurance scheme for serving staff.

Persons affiliated to the Organisation’s Medical and Social Insurance Scheme under Article 16, paragraph 2, of these Regulations shall pay the full cost of their insurance.

^{^[1]} Note: as amended by Resolution CM/Res(2008)1 of 16 January 2008. The text of this Resolution contains footnotes that have become obsolete and are therefore not published. As amended by Resolution CM/Res(2013)65 of 11 December 2013, with effect from 1 January 2014 and Resolution CM/Res(2016)18 of 18 October 2016, with effect from 1 January 2017.

^{^[2]} Note: as amended by Resolution CM/Res(2016)18 of 18 October 2016, with effect from 1 January 2017.

^{^[3]} Note: as amended by Resolution CM/Res(2013)65 of 11 December 2013, with effect from 1 January 2014 and Resolution CM/Res(2016)18 of 18 October 2016, with effect from 1 January 2017.

^{^[4]} The salary referred to here comprises basic salary and, where applicable, the household allowance, the basic family allowance, the expatriation or residence allowance and the language allowance.

[5] Note: as amended by Resolution CM/Res(2016)18 of 18 October 2016, with effect from 1 January 2017.

^{^[6]} The salary referred to here comprises basic salary and, where applicable, the household allowance, the basic family allowance, the expatriation or residence allowance and the language allowance.