Thursday 08 August 2019
With readers regularly reporting difficulties and delays in obtaining health cover in France, we consider the complaint procedures that are in place.
Obtaining health cover in France is no longer the simple formality that once was the case.
Since 2012 the French government have imposed a 5-year residence requirement on early retirees from the EEA, and since 2014 UK early retirees no longer have access to an S1 certificate from the British government.
In practice, the French government have relented on the 5-year rule, but most early retirees are being put through the bureaucratic mincer in order to obtain health cover, with the need, in particular, to prove 'sufficient resources'.
In addition, although health cover is granted automatically to those who set up a business in France, since the introduction of PUMA health system in 2016, spouses not in the business have to make their own application for cover, in a process that involves the usual paper-chase and substantial delays.
We also hear of other cases where local health authorities have wrongfully refused health cover to those who have been recently widowed, or where they have imposed a health charge on an applicant in breach of the rules for such charges or demanding documents that have no basis in the application procedure.
Many of these issues were highlighted in a recent report from the French Ombudsman, the Défenseur de Droits, which we covered in our article Access to French Health System by EEA Residents.
Although, in the end, most of these problems appear to be resolved satisfactorily, it is not before a great deal of stress and cost to those involved.
In the face of such problems, it is important for those involved 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.
The first step to take is to make a formal complaint – called a 'réclamation' – to your local health authority, the Caisse Primaire d’Assurance Maladie (CPAM).
A complaint can be made in any form, but by far the best approach is a recorded delivery letter to the CPAM, which is 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 demand, 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.
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 the 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.
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.
As we indicated in the article mentioned above, the ombudsman has received complaints about problems being faced by EEA nationals, so they are likely to be conversant with the issues, and sympathetic.
If your appeal is rejected by the CRA, within two months of the decision you can bring a legal action, which since 2019 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.