How to contest a Cpam health treatment refusal

As a French resident, if you have received a decision from your Cpam (caisse primaire d'assurance maladie) refusing you healthcare treatment, you have the right to contest it. 

There are several steps you can take depending on the nature of the refusal, and each step offers a different level of escalation.

Make a réclamation 

If you are dissatisfied with your Cpam’s decision or if there has been a delay in reimbursement, the simplest step is to file a réclamation (complaint). 

This process allows you to formally address practical issues, such as delayed reimbursements or lack of clarity on the refusal.

You can submit your complaint in person, by letter, or via your online account on Ameli. 

Cpam usually has a dedicated complaints section, and your complaint will be reviewed by a different person than the one who made the original decision.

The médiateur service

If the réclamation does not resolve the issue or you do not receive a response within a reasonable time, you can take the matter further by seeking mediation through the médiateur (ombudsman) service.

To contact the médiateur, write to them at your Cpam’s address or log into your Ameli account and go to the ‘Mes démarches’ section. 

If you cannot find the appropriate option, type contacter le médiateur into the chatbot to guide you. 

The médiateur is independent and impartial and will help clarify the reasons behind the Cpam's decision.

Cpams do not always explain fully and it may just be that you did not submit the correct documents.

The médiateur will assess whether your request is valid and while they cannot force the Cpam to reverse its decision, they can suggest a resolution. 

If the médiateur agrees to help with your case, this will pause any deadlines for formal complaints.

Formal complaints

If you wish to contest an administrative decision, such as a refusal to reimburse a treatment or allow you to join the Complémentaire santé solidaire (CSS), you should first file a formal complaint with Cpam’s commission de recours amiable (CRA) within two months of receiving the refusal letter.

The refusal letter will explain how to appeal and once submitted, Cpam will respond by post. 

If the CRA's decision is unsatisfactory, or if you do not receive a response within two months, the next step is to go to court. 

You then have two months to apply to the pôle social at your nearest tribunal judiciaire, either alone or with the help of a lawyer, union representative, or family member.

The last possible stage is the Cour de Cassation, France’s top appeal court.

Medical appeals (CMRA)

If your complaint relates to a medical condition, such as disputes over your disability level for benefits, you must apply to the commission médicale de recours amiable (CMRA). 

You will need to apply within two months by registered post (lettre recommandée avec accusé de réception) to the address that should be on the refusal letter.

The process is similar to the CRA, but if necessary, the CMRA may require you to attend a medical examination.

If you do not receive a response from the CMRA within four months or disagree with their decision, you can escalate the issue to court within two months.

Discriminatory care refusals

In cases where a medical professional refuses to provide care based on discriminatory grounds (eg. gender, sexual orientation or race), you can file a complaint with the professional’s regulatory body. 

They will investigate the issue, starting with a conciliation session where the professional must explain their actions.

Additional support

For further guidance, contact Cpam’s English-speaking helpline on 08 11 36 36 46.

Cleiss, the international social security advice body, can also offer advice on expatriates' entitlements and the healthcare system in France. Phone them on 01 45 26 33 41.