How to contest a CPAM decision
Conciliateurs are an independent service to help pursue a complaint against the health authorities.
HEALTH conciliateurs are official mediators who can contest CPAM decisions or help to explain why they have been made.
The independent service exists as a secondary route to pursue complaints against the health service. It deals with a range of problems including many faced by readers.
These include: early retirees who had E106 forms but who have not yet been allowed to join the health system despite the government promising its ban on “inactive foreigners” joining the CMU would not be retrospective or those who have lost their right to 100% healthcare cover under incapacity benefit because they started getting an old age pension.
Here we look at the main ways to contest CPAM decisions.
If you have received a refusal letter from your CPAM the first avenue is called une réclamation (complaint).
You can do it by telephone or in person by letter or email. If the response is not satisfactory or you get no response in three weeks, you can saisir (apply to) the conciliateur. Each CPAM has one of these official mediators who are impartial, neutral and independent.
Applying to them does not stop the other formal procedures open to you to contest the decision. The réclamation is your initial complaint and the CPAM will review any decision made and try to explain the reasons.
Josiane Cazabieille, who is in charge of the conciliateur service said CPAMs are encouraged to have a dedicated réclamation service so the person looking into your complaint is not the same as the one who made the initial decision.
In many cases this phase is enough to sort the matter out. You should get a written response. If you do not get one in three weeks, or are dissatisfied with it, you can apply to the conciliateur.
In tandem with this, if you want to formally contest the decision you should apply to your CPAM’s Commission de Recours Aimable (CRA) within two months of the original refusal, a course which the refusal letter should advise.
If your complaint concerns a decision relating to your medical condition (as opposed to a purely administrative one), you should first, within a month of the refusal, ask your CPAM to organise an expertise médicale.
This is done in writing, specifying the name of a doctor you know who can assist the CPAM in designating the doctor who will examine you. You will be invited to attend the designated doctor's clinic.
Your CPAM will consider the doctor's opinion and only if you disagree with their conclusions based on this expertise do you then apply to the CRA (however do not miss the two-month deadline).
If you contest the CRA's decision you have two months to apply to the Tribunal des Affaires de Sécurité Sociale, which is based at your nearest tribunal de grande instance (court where serious cases are heard).
You can do this alone or by representation from an avocat, a union rep or a family member. The last possible stage is the Cour de Cassation.
Mrs Cazabieille said: “These formal procedures must be undertaken in the time-limits prescribed. However there is no limit for applying to the conciliateur, who may be able to get the CPAM to look at your case again.
“However do not approach the conciliateur in the first place - make a réclamation. The conciliateur will listen to the applicant and ask extra questions if necessary and try to understand. Firstly they will make sure the person fully understands the reasons for the CPAM decision.
“Sometimes CPAMs do not explain fully or simply refer to an article in the Code de la Sécurité Sociale. It could just be the person did not supply the correct documents with their request. The conciliateur can review the situation and see if the person does have a right to what they asked for.
“Last year in 50% of cases conciliateurs confirmed the CPAMs decision but helped the person understand it better. In 35-40% of cases they were able to get the decision changed thanks to a deeper study.
“However there are millions of réclamations each year and only about 8,000 cases treated by conciliateurs.”
Contact details for your nearest conciliateur are on the www.ameli.fr site.
Put in your postcode into votre caisse> modifier>votre caisse>vous informer>la conciliation.
This may not work for all CPAMs in which case you will have to ring them.
For further information follow this link and look at the réclamations et voies de recours section. (In French).
You can also get advice from the state health insurance English-speaking helpline on 08 11 36 36 46 or from CLEISS on 01 45 26 33 41
