18. French Health - Complaints System
Obtaining health cover in France for some is no longer the simple formality that once was the case.
Although, in the end, most problems appear to be resolved satisfactorily, it is frequently not before a great deal of stress and cost to applicants.
In the face of such problems, it is important for applicants to be aware of the various complaints procedures that are in place, short of legal action, which can often unlock an impasse that may be encountered.
You may also have complaints about charges that have been imposed, or the service you have received.
What are the steps you need to take?
i. Local Health Authority
If you have a complaint about charges, reimbursements or access to health, in the first instance you should contact your local Caisse.
For non-active persons it is the Caisse Primaire d’Assurance Maladie (CPAM) as is increasingly the case for those in a professional/business activity, although such persons may need to contact SECU.
A complaint can be made in any form, but by far the best approach is a recorded delivery letter to the CPAM, clearly marked 'réclamation’ in the title of the letter.
This approach is best used where you consider there has been an unreasonable delay in processing of your enquiry/application, a problem we are aware is widespread.
If within a reasonable period you do not obtain a response from your CPAM, or you have a decision with which you disagree, you can refer the matter the local médiateur, sometimes also called conciliateur. Each CPAM has their own médiateur.
As a preamble to engagement of the médiateur all hospitals have a Commission des Usagers (CDU), whom you may also wish to contact, as they can then start mediation proceedings. The CDU can inform you of the remedies that may be available to you and how to approach your complaint.
The role of the médiateur is primarily to deal with dysfunction or anomalies, but they are also able to intervene against a decision of the CPAM with which you disagree.
However, the médiateur does not have executive powers, so they can only make a recommendation.
You cannot bring them into the process unless you have at least tried to solve the problem directly with your CPAM in the first instance, except where you have been refused health care by a doctor or you have a serious illness and you are unable to obtain an appointment within a reasonable period.
You can write to the médiateur at the address of your CPAM, or send an e-mail, using the address that you will find on their website.
You need to set out your problem and include in the submission written correspondence you have had with your CPAM. You should also include your telephone number and e-mail.
The referral to the médiateur does not prevent you from using the two remaining routes of redress considered below, although you cannot do so if you have started a legal action.
iii. Appeal Panel
To contest a decision made by your CPAM you can appeal to the Commission Amicable de Recours (CRA).
The CRA is composed of representatives of the CPAM as well as independent members.
The appeal must be made within two months of notification to you by CPAM of their decision.
The process takes place by submission of a written appeal to the CRA; you will not be asked to make an appearance in front of the CRA. The use of a recorded delivery letter is imperative. You can write to them at the address of your CPAM.
A decision is normally given within two months of making the appeal. Unfortunately, the CRA can also adopt the regrettable practice of 'silence means rejection', so if you have not heard within this period then the appeal is considered to have been rejected.
An appeal to the CRA is obligatory before you can bring a legal action
The national ombudsman in France is called the Défenseur des Droits.
You can either make a complaint to the ombudsman by completing an on-line form, or by simply sending a letter at Saisir le Defenseur des droits.
In some areas it is also possible to arrange an interview with a local official of the ombudsman.
Before you can call in the ombudsman you need to be able to demonstrate that you have attempted to resolve the problem with your CPAM. Ideally, this should be way of letters or mails, but may also be by way of statements concerning meetings you have held with them or by telephone calls you have exchanged.
The ombudsman has received complaints about problems being faced by EEA nationals, so they are likely to be conversant with the issues, and sympathetic.
v. Legal Action
If your appeal is rejected by the CRA, within two months of the decision you can bring a legal action, which is heard in the Tribunal de Grande Instance (TGI).
You can also bring a legal action if you have not been able to resolve the problem through the médiateur or the Défenseur des Droits.
However, you cannot simultaneously make an appeal to the CRA or the ombudsman and bring a legal action.
Clearly, in such circumstances, you will need to engage an avocat who specialises in such appeals.
vi. Medical Treatment
If you have a complaint about medical treatment then, in the first instance, you should take it up with service concerned, failing which you can make a formal complaint to a conciliation body called Commissions régionales de conciliation et d'indemnisation des accidents médicaux, des affections iatrogènes et des infections nosocomiales (CRCI). These regional boards have the power to award compensation payments.
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