Cpam: ways to contest a health treatment refusal

Any negative decision by your Cpam health authority, refusing you treatment rights, can be contested. How you do this depends on the issue and there are several levels to which you can take your complaint.

Make a réclamation

If you are dissatisfied with your Cpam’s medical reimbursements service for practical reasons (it takes too long, it failed to reimburse you for a treatment you submitted a claim for and you do not understand why...), the simplest avenue is une réclamation (complaint). You can do this in person, by letter or via your account at ameli.fr. Cpams usually have a complaints section, and the person dealing with your issue will probably not be the person who took an initial refusal decision.

The médiateur service 

In many cases a simple réclamation may resolve the issue. However if the response is not satisfactory or you do not receive a reply in a reasonable time, you may wish to either pursue a more formal complaint or seek mediation. 

You can saisir (apply to) the médiateur in your Ameli account in Mes démarches (if you cannot find a suitable heading, contact put contacter le médiateur into the chatbot). They are impartial and independent. You can also write to them at your Cpam’s address.

First, they will make sure you have fully understood the reasons for the Cpam decision. Sometimes Cpams do not explain adequately. It could also just be that you did not supply the correct documents with their request. 

The service can review the situation and see if you do have a right to what you asked for and if they consider the matter is within their competency, they will help to resolve it. They cannot force the Cpam to comply but will suggest a solution. Note that if the médiateur confirms that they will deal with your case, this suspends any time limits for making formal complaints.

Formal complaints

If you want to formally contest an administrative decision, such as a refusal to reimburse a treatment, to pay out sick pay or to allow you to join the Complémentaire santé solidaire (CSS), you should first apply to your Cpam’s commission de recours amiable (CRA, amicable solutions commission) within two months of the original refusal letter. Details of how to do this will be in the refusal letter. You receive a reply by post.

If you want to contest the CRA’s decision (or none is received in two months), the final option is to go to court. You have two months to apply to the pôle social at your nearest tribunal judiciaire. You can do this alone or by representation from an avocat, a union representative or a family member. The last possible stage is the Cour de Cassation, France’s top appeal court.

If your complaint concerns a decision relating to a medical condition (for example concerning your level of disability or incapacitating illness, for purposes of a disability pension or benefits) you should apply to a body called the commission médicale de recours amiable (CMRA), also with the court option as a last resort. Apply within two months of the original letter by registered post with reply slip to the address that should be on the refusal letter. CMRAs are regional, for the area where the Cpam is located.

The CMRA may ask you to come for a medical examination and you can ask to be accompanied by a doctor who knows you. The request to come in for the examination will be sent at least two weeks before the examination date. In this case any court action should be started within two months of receiving the decision of the CMRA or within two months of the expiry of a four-month period after making your complaint if there is no response.

There is a specific complaints procedure where a medical professional refuses you care on discriminatory grounds (gender, sexual orientation, racial or national origins etc). In this case you can complain to their professional body, which will investigate, initially calling you in for a conciliation session with the professional, who should explain their behaviour.

The Cpam English-speaking helpline on 08 11 36 36 46 can also give advice as can the international social security advice body Cleiss on 01 45 26 33 41. Cleiss’s experts should be knowledgeable about expatriates’ entitlements and the way the French and foreign systems work.