Administrative dispute with the health insurance fund

Verified 17 November 2023 - Legal and Administrative Information Directorate (Prime Minister)

How can you challenge an administrative decision (e.g. a refusal to reimburse care) made by a Social Security organization? This claim must be submitted to the Amicable Appeals Board of your health insurance fund. If this mandatory prior remedy fails, the court of law has jurisdiction. On appeal, the Social Chamber of the Court of Appeal has jurisdiction. We're giving you the basics of the regulations.

Step-by-step approach

The appeal to the Amicable Appeals Board of your health insurance fund is obligatory before any litigation.

What disputes are open to the Commission for an amicable appeal?

The Amicable Appeals Board shall have jurisdiction in the following disputes, which fall within the general field:

  • Disputes between insured persons and a social security body
  • Disputes concerning administrative decisions on membership, contributions and benefits.

For example, one of the following disputes may arise:

  • Decision to refuse membership
  • Decision to refuse payment of a benefit
  • Decision on a calculation of contributions.

FYI  

You can refer to the sickness insurance conciliator. It is not intended to settle the dispute, but to establish or re-establish a communication between a CPAM and you. This will help explain the decision being challenged and help you find a solution that would end the dispute.

Who can bring an action before the Commission for amicable redress?

Any insured person may bring an action before the Amicable Appeals Board from his sickness insurance fund.

When can the Court of Appeal bring an action before the Commission?

You must refer the matter to the Amicable Appeals Board in the two-month period from the date of notification of the decision you are challenging.

How can I refer a case to the Amicable Appeals Board?

You must contact the Amicable Appeals Board of your health insurance fund by registered letter with AR: titleContent.

Referring your health insurance fund to the Amicable Appeals Board by registered letter with AR can help to prove, if necessary, that the Commission has indeed been referred within the 2-month period.

How is the request to the Amicable Appeals Board dealt with?

The Amicable Appeals Board of your health insurance fund decides on the documents it has.

The decision:

  • You are notified within the 2 months from receipt of the request
  • East reasoned
  • Indicates the time limits and methods of appeal to the court.

After 2 months, the absence of a reply from the Amicable Appeals Board means that your request is rejected.

This implied rejection may be challenged before the court.

How to apply to the court of law?

You must address your request to the court of justice (social pole) within 2 months:

  • From the date of notification of the decision you are challenging
  • Or, in the absence of a reply from the Amicable Appeals Board, as from the expiry of the 2-month period available to it to reply to your complaint.

The competent court is the court of the place of your domicile. Its address shall be indicated, where appropriate, on the acknowledgement of receipt or the decision of the Amicable Appeals Board.

At the hearing, you may appear yourself, or be represented or assisted by counsel.

On the spot

You can file your request and the documents, in 2 copies, to the Service d'accueil unique du liticiant (SAUJ) of the court of your domicile.

Its address shall be indicated, where appropriate, on the CRA acknowledgement or decision and by the credit union.

Application for referral to the Court - Social Security and Social Assistance Disputes

Who shall I contact
By mail

You can send your request by registered letter with AR: titleContent in the court of your domicile.

This request and all the documents requested in the form shall be submitted in duplicate.

Application for referral to the Court - Social Security and Social Assistance Disputes

Who shall I contact

How is the application for judicial review handled?

The court will summon you by mail at least 15 days before the hearing.

You have to introduce yourself to the hearing. A person of your choice can assist you (lawyer, union representative, etc.).

FYI  

if you are assisted by a lawyer, you can benefit from legal aid.

The court registry notifies you of the decision. The notification indicates the time limits and remedies before the court of appeal.

Where the decision of the court of first instance is given (dispute over an amount greater than €5,000 or indeterminate amount), you can appeal to the social chamber of the court of appeal, in a one-month period from the date of notification of the judgment of the court.

A lawyer is not required before the Court of Appeal.

The court registry notifies you of the decision.

Who shall I contact

If you challenge the decision of the Court of Appeal, you must file the appeal at the Registry of the Court of Cassation within a period of 2 months from notification of the decision of the Court of Appeal.

The same shall apply if the decision of the court concerned a dispute of less than €5,000.

Who shall I contact

You need to call on a lawyer at the Council of State and the Court of Cassation:

You can benefit from legal aid.

Who can help me?

Find who can answer your questions in your region

  • Health Info Rights

    A telephone line created by a collective of user associations to provide legal or social information related to health

    By telephone

    01 53 62 40 30

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