Cover for member' spouse

Application of Articles 3 and 6 of the Rules on Sickness Insurance for Officials of the European Communities
Updating for 2004

Article 3 of the Rules on Sickness Insurance provides that a member's spouse is to receive primary cover under the member's insurance, provided that the spouse is not gainfully employed. If your spouse has no professional income from gainful employment, pension or allowances (unemployment, invalidity...), you do not have to do anything.

If the spouse is gainfully employed¹ or in receipt of income deriving from previous gainful employment (for example a retirement or invalidity pension or some other allowance), he or she may be entitled to supplementary reimbursement under the Joint Sickness Insurance Scheme, provided that both the following conditions are fulfilled:

1. he or she must be covered against the same risks as those covered by the scheme, by virtue of some other legal provisions or rules;

2. his or her annual income from such employment before tax² must not exceed the basic annual salary of an official in the first step of Grade C5, subject to the weighting for the country in which he or she receives that income from gainful employment. The relevant amounts for the various countries are set out at the end of the document.

In order to enable their records to be updated, all members concerned must send documentary evidence of their spouse's income from present or previous gainful employment to: (see list ).
 
The relevant documents are:

• if the spouse is employed or retired, the tax certificate relating to income received during the previous year or, pending the availability of such certificate, a certificate from the employer indicating the details of the income received during 2003. If the spouse took up employment only recently, the most recent monthly pay slip should be produced, indicating the prospective number of monthly payments in the year;
   

• in respect of a self employed spouse, the tax certificate relating to income received during 2003 or, pending the availability of such certificate, the certificate relating to 2002. For spouses self-employed in Belgium, proof of insurance against minor risks ("petits risques") must also be submitted.

As from 1 July 2004, reimbursement of medical expenses for spouses currently receiving supplementary cover will be suspended pending receipt of the requisite documentary evidence.
 
Save in cases where the spouse stops working during the course of the year or where there is a significant alteration in the circumstances of his or her employment (e.g. switching from full-time to half-time work and vice versa), the decision providing supplementary cover will be valid from 1st July 2004 to 30 June 2005.
 
Members must notify the relevant office responsible for settling claims of any change in the circumstances of any person covered by their insurance, having regard to Article 6(1) of the Rules and Article 72(4) of the Staff Regulations, which provide that members must declare the benefits which those persons can claim and which are received by them under any other sickness insurance scheme provided for by law or regulation.
 
To make a claim for a complementary reimbursement members should:

1. complete a claims form, clearly indicating the name of the patient;
    

2. attach all supporting documents:

   • copies of doctors' statements and the originals of chemists' receipts,

   • the statement of reimbursements provided by the mutuelle;
      

3. send the claim to the Claims Office.

Footnotes

1. Even if the work is not full time or produces little income, for example free lance work, consultancy work or other self employed work.

2. This means gross income minus deductible expenses and social
   security contributions.