Appealing a refusal of coverage for scheduled treatment

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The following applies if you intend to seek treatment in another EU/EEA country or Switzerland. For certain types of care, you must be issued a certificate of prior authorization (S2 certificate) by your French health insurance fund. Without this document, your treatment will not be covered.

Your authorization (S2 certificate) will be granted if the following conditions are met:

You will receive notice of prior authorization or refusal of coverage from your health insurance fund within 14 days of receipt of your application. If you receive no response within this timeframe, your application has been approved.

You wish to appeal a denial of an S2 certificate application

Appealing an administrative decision

You must first apply to your health insurance fund's arbitration board (“Commission de recours amiable”/ CRA) (list of health insurance funds – CPAM) and send your request within a 2-month deadline following notice of the decision you wish to dispute.

If the Arbitration board (“Commission de recours amiable”) denies your application, you may appeal to the social security affairs section (“pôle social”) of the court (“Tribunal judiciaire”/TJ) with jurisdiction over your place of residence, within a 2-month deadline following notice of this denial. If you receive no reply from the Arbitration board within 2 months of receipt of your application, this means that your application has been denied. You may then appeal to the TJ within 2 months of expiration of this 2-month waiting period.

If your claim has a monetary value of less than 5,000 euros, you will need to file a submission either online or by sending a registered letter to the office of litigant services (“service d’accueil unique du justiciable”/ SAUJ) at the court (“Tribunal Judiciaire”) whose address appears on the notice of the arbitration board (« commission de recours amiable ») decision which you are appealing (the application form is available online). In order to be valid, submissions filed online must also contain the applicant’s email address and telephone, which they enter when consenting to a paperless procedure, or those of the applicant’s lawyer. Claims with a monetary value of more than € 5,000 can be submitted to the court (“Tribunal Judiciaire”) with jurisdiction by writ issued by a bailiff (“huissier”) or a lawyer.

In addition to the grounds for your application, your submission must include the full identity of all parties, all required supporting documents, a copy of the previous action you have taken, and a copy of the decision from the arbitration board (“commission de recours amiable”).

As a last resort, you can appeal before the court of appeals (“Cour d'appel”) specially designated and/or the Court of Cassation (“Cour de cassation”).

If your decision from the TJ is handed down “en dernier ressort” (this is the case for disputes involving an amount less than € 5,000) you can apply to the Court of cassation (“Cour de cassation”) within a 2-month deadline following the date of notice from the TJ.

If the decision from the TJ is handed down “en premier ressort” (this is the case for disputes involving an amount above € 5,000 or when the amount is undetermined), you can appeal before the Social division of the Court of Appeals (“chambre sociale de la cour d'appel”) within a 1-month deadline following notice from the TJ. If you are not satisfied with the decision from the Court of Appeals, you can then apply to the Court of Cassation (“Cour de cassation”) within a 2-month deadline following notice from the Court of Appeals.

The list of specially designated Courts of appeal (“Cour d'appel”) and TJ is available at the following address : www.justice.fr/recherche/annuaires

Appealing a medical decision

You must first apply to your French health insurance fund (“caisse d'assurance maladie”) for a medical assessment. You must submit a written application by registered letter (“lettre recommandée”), specifying the points that you are disputing as well as the name and address of the doctor you have appointed, to your French health insurance fund. You may also drop it off in person at your health insurance fund's reception desk. Your application must be submitted within a 1-month deadline following the date of notice of the decision you are disputing.

To dispute how your health insurance fund (CPAM) applies the expert's findings, you can appeal to your CPAM's arbitration board (“Commission de recours amiable”/ CRA) within a 2-month deadline following notice of the decision you wish to dispute.

You may then choose to bring proceedings and file a submission either online or by sending a registered letter to the office of litigant services (“service d’accueil unique du justiciable” / SAUJ) at the court (“Tribunal Judiciaire”/TJ) whose address appears on the notice of the arbitration board (“commission de recours amiable”) decision which you are appealing (the application form is available online). Your submission must be filed within 2 months of the date you received the notice of the arbitration board’s decision or, if you do not receive a reply from the Board, within 2 months of the end of the 2-month deadline it had to reply to your complaint. In order to be valid, submissions filed online must also contain the applicant’s email address and telephone, which they enter when consenting to a paperless procedure, or those of the applicant’s lawyer. Claims with a monetary value of more than 5,000 can be submitted to the court (“Tribunal Judiciaire”) with jurisdiction by writ issued by a bailiff (“huissier”) or a lawyer.

In addition to the grounds for your application, your submission must include the full identity of all parties, all required supporting documents, a copy of the previous action you have taken, and a copy of the decision from the arbitration board (“commission de recours amiable”) as well as the name and address of the doctor you have appointed to receive any medical documents.

As a last resort, you can appeal before the court of appeals (“Cour d'appel”) specially designated and/or the Court of Cassation (“Cour de cassation”).

If your decision from the TJ is handed down “en dernier ressort” (this is the case for disputes involving an amount less than € 5,000) you can apply to the Court of cassation (“Cour de cassation”) within a 2-month deadline following the date of notice from the TJ.

If the decision from the TJ is handed down “en premier ressort” (this is the case for disputes involving an amount above € 5,000 or when the amount is undetermined), you can appeal before the Social division of the Court of Appeals (“chambre sociale de la cour d'appel”) within a 1-month deadline following notice from the TJ. If you are not satisfied with the decision from the Court of Appeals, you can then apply to the Court of Cassation (“Cour de cassation”) within a 2-month deadline following notice from the Court of Appeals.

The list of specially designated Courts of appeal (“Cour d'appel”) and TJ is available at the following address : www.justice.fr/recherche/annuaires.