Making a Retrospective NHS Continuing Healthcare Funding Claim
Do you know whether your loved one ever had an assessment of their eligibility for NHS Continuing Healthcare Funding? Clinical Commissioning Groups have a legal duty to assess a person’s eligibility for funding, wherever it appears to the professionals involved that there is a need to do so.
Unfortunately, whether due to imperfections in the system, a reluctance to allocate resources towards an assessment, a lack of training and understanding amongst professionals, many people slip through the net and don’t get an NHS Continuing Healthcare Funding assessment. In such circumstances, it is possible to request a retrospective (backdated) NHS Continuing Healthcare Funding assessment.
Retrospective NHS Continuing Healthcare Funding Claims
The retrospective eligibility criteria is the same as that which is applied in contemporaneous assessments, but the process of making a claim is quite different. Below, we explain the basic steps you need to take:
Are You in Time to Claim?
In England, it’s no longer possible to ask a Clinical Commissioning Group (CCG) to retrospectively assess a person’s eligibility for NHS Continuing Healthcare Funding before 31 March 2012. You can still request an assessment of eligibility from 1 April 2012 onwards.
It’s likely that the NHS will make another announcement to prevent people from making a claim for the period after 1 April 2012, but it hasn’t happened yet and, at the time of writing this, there has been no further announcement.
You need to decide what period of time you want to claim for. Do you want to ask for an assessment from the date your loved one was admitted to the care home? Up until the date of their death if they’ve since passed away? Up to the present day? Perhaps they’ve had an assessment of their eligibility recently and you want to claim for the period of time prior to it. In any case, be clear on your dates you want to claim for.
If Your Loved One was Already Assessed
It’s important to realise that retrospective claims happen because the NHS often fails to undertake NHS Continuing Healthcare Funding assessments for people when it should have done. If your loved one has already been assessed, it’s not possible to ask for another retrospective assessment of that period, because there is an appeal process in place for people who have been assessed already and aren’t happy with the decision.
Having said this, it’s rarely this straightforward. What if a long time has passed since the assessment? What if you weren’t aware you could appeal the decision? What if there has been more than one assessment, but a long period of time between them when your loved one’s needs are unknown to the NHS?
We recommend always seeking legal advice on these points. At Simpson Millar, our Care Home Lawyers offer a full review and advice service, following which we can advise you whether it might still be possible to make a retrospective claim.
If you made a retrospective claim, but it has been declined because your loved one was previously assessed, we recommend asking for a full copy of the assessments and associated decision letters and seeking legal advice as a matter of urgency.
Legal Advice and Support
It isn’t a requirement to instruct a Solicitor or a Lawyer to make a retrospective NHS Continuing Healthcare Funding claim on your behalf. However, our Care Home Lawyers have recovered over £12 million in care fees for our clients since 2013, so it can be very reassuring to know that your case is in the hands of an expert who specialises in Continuing Healthcare law.
With Simpson Millar, you can be assured that your case will be presented in the best possible way, expertise will be on hand when issues arise and that all deadlines are met, so you can concentrate on other matters.
Which CCG Should Deal with Your Claim?
To determine which CCG is responsible for dealing with your claim, you need to find out which GP surgery your loved one was registered with immediately prior to the start date of your claim period. If your loved one has been registered with the same GP throughout, this simplifies matters.
All GP surgeries fall under a particular CCG. Once you’ve determined which one this is, you’re ready to request a retrospective assessment.
But be warned - for those who submit their request to the wrong CCG, the CCG in question will acknowledge your request and forward it on to the correct CCG. Having said this, we’ve been contacted by many people who have had their claims rejected on this basis and it would appear that some organisations will view this as an easy reason to reject a claim. If this has happened to you, we recommend you get legal advice as soon as possible.
Submit Request for a Retrospective NHS Continuing Healthcare Assessment
We always recommend submitting your request for a retrospective assessment in writing and sending your letter by Royal Mail Recorded Delivery or Royal Mail Special Delivery. CCGs are very large organisations and correspondence can go astray.
You should always be clear in your letter as to what you are asking for and don’t forget to provide details of the person being assessed and their NHS number if you have it. It can be helpful to set out the reasons why you believe your loved one was eligible for NHS Continuing Healthcare Funding.
The CCG should acknowledge your claim and provide confirmation of the next steps. They will usually ask you to prove that you have the necessary legal authority to act on behalf of the individual concerned, but if you’re requesting a retrospective assessment for yourself, then there’s no need for this.
The CCG will begin to gather the evidence needed for the assessment, including further information from you and it’s crucial at this stage that you make out your case for eligibility clearly and persuasively.
If for any reason the CCG doesn’t accept your claim, or initially accepts your claim but later rejects it, it’s important that you seek legal advice as to the validity of its decision.
Our Care Home Lawyers have helped many people to submit their claim, making out the key strengths of their cases, as well as people who have had claims wrongly denied.
If you need help making a retrospective NHS Continuing Healthcare Funding claim, then please get in touch with our Care Home Fees specialists who will be happy to help you.
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