Care Home Fee Claims

  • As of mid-2015 there were 11.4 million over 65s and 550,800 people aged 90+.
  • It’s a fact of life that as we age, we need more and more caring for whether this is just due to age or health-related complications.
  • Unfortunately health-related complications can cost people substantial amounts of money in care costs despite qualifying for NHS funding.
  • Many people who qualified for such funding were denied it and can no claim for incurred costs as far back as 1st April 2012. 
 

Need to know

  • Many people who pay for care due to health issues, either at home or in a care home, do not need to as it should have been funded by the NHS.
  • In order to be eligible for the funding, an assessment is required by the NHS to determine whether the person necessitating care has a ‘primary health need’
  • It doesn’t matter if the person in need of care or their family had savings or assets, the funding is not means tested so as long as care is required for health reasons then the qualifying criteria is met.
  • April 2012 saw a cut off point for retrospective claims but there are still many people who are paying for care when they needn’t be.
  • This type of claim is not due to care home negligence and is not paid for by the care home in question but is simply because fees have been paid by people despite them or their relative qualifying for NHS funding.
  • This claim is only for residents in England, unfortunately the laws are different in the rest of the UK.
 

Reasons to claim

  • If yourself or a relative were assessed previously for funding and were rejected but your condition has since worsened
  • If yourself or a relative was discharged from a hospital straight into a care home
  • If yourself or a relative received NHS Nursing Care but did not have an assessment for the funding which would have paid for accommodation
  • If yourself or a relative did not receive an assessment and automatically assumed, or were told, that you had to pay the fees
 

How to claim

  • Request a preliminary assessment from your local Clinical Commissioning Group or Commissioning Support Unit CCG/CSU (formerly Primary Care Trust’s) continuing healthcare co-ordinator who will go through a quick checklist to determine if a full assessment is required
  • If they agree a full assessment is required, one will be undertaken and a decision should be reached as to whether or not costs will be paid by the NHS.
  • If your claim is rejected then you can appeal the decision.
  • You must first write to your Clinical Commissioning Group (CCG) or Commissioning Support Unit (CSU) with evidence outlining why you think your case was wrongly turned down. This can include your own personal notes on the condition of the person in question which are backed up by medical notes.
  • If the CCG/CSU rejects or cannot resolve your issue, they will call an independent review panel chaired by the Strategic Health Authority (SHA). If they fail to call a review panel you can write to the SHA explaining that you disagree with the CCG/CSU’s decision and request an independent review.
  • The panel will decide to uphold or disagree with the original assessment if they believe the decision wasn’t based on the correct criteria. During this phase, the person in need of care can give evidence whether that be themselves or through a family member, carer or an independent advocate.
  • If the independent panel disagree with your case then your final option is to go to the Health Ombudsman who have a full explanation of how to complain to them on their website.   
  • The above also applies process also applies when a patient has passed away. The claim can then be brought on behalf of the deceased patient’s estate by the correct personal representative. 
 

If you want to use a claims company...

We recommend...

Care Home Claims


Why we like it:

  • No win no fee
  • You enter your details and an adviser will call you back
  • They will then handle the process for you

Watch out:

  • You can make these claims yourself
  • They charge 25% + VAT

The inside track

  • If you are undertaking your claim yourself and are struggling, you can turn to the NHS Patient and Liaison Service (PALS) who will offer confidential advice as well as support and information on health-related issues to patients, families and carers. PALS can particularly offer advice around making complaints and improving service.
  • You can also contact Age UK Information and Advice who have a lot of expertise in this area, they can be contacted on 0800 169 2081

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