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Degree of care declined? How to defend yourself with objection and complaint
Decision of the care fund on the care application
An expert opinion is drawn up to determine a level of care. The expert informs the long-term care insurance fund of the result of the assessment as a recommendation. Based on the recommendation of the MDK in the report, the care fund decides on the level of care.
You will be informed of the decision in writing. There are two options here: approval or rejection.
But even if the application does not provide the desired level of care or a service that you have applied for is not approved, you can take action against it with an objection and legal action.
The long-term care insurance mostly bases its decision on the expert opinion of the MDK. This will be sent to you with the notification. If this is not the case, you should request it, as it is important to justify the care wheel.
It is encouraging when the long-term care insurance company recognizes the desired level of long-term care and approves the requested benefits. The benefits are usually granted retrospectively from the month of application.
Lodge an objection
In some cases, however, applications are rejected or a lower level of care is recognized than the person in need of care had hoped for. If you do not agree with the decision of the long-term care fund, you have one month from receipt of the notification to lodge an objection with the long-term care fund. If there is no reference to the possibility of filing an objection in the notification, the period is one year.
When calculating the deadline, start with the day on which you received the letter. If you don't know the date, you can rely on the date of the notice when calculating the deadline. Then you are on the safe side. To be on the safe side, you should send your objection by registered mail with acknowledgment of receipt. You can also send it by fax. Then, in case of doubt, you can prove that you have met the deadline. However, it is not possible to submit the objection by email. You can use our free sample letter to object.
This is how the objection procedure works
In the objection procedure, the long-term care insurance fund reviews your decision again and a second opinion is usually drawn up. This report is either carried out according to the files or with a renewed visit to the person in need of care. All medical documents should also be kept ready at the next appointment so that the expert can again get a comprehensive picture of the situation.
If the objection is accepted, you will receive a positive answer, the so-called remedy. If the long-term care insurance company rejects it, it issues the objection notice.
Lawsuit at the social court
If the objection does not bring the desired result, those affected can still go to the social court. Here it is also important to adhere to the period of one month after receipt of the notice of objection. The date of receipt also counts here. If the letter arrives in a yellow envelope, keep it. Since it is then a registered mail, the postman has noted the date on which he posted the letter or gave it to you. If you do not remember when you received the letter, you can use the date of the notification as a guide. You can submit the complaint to the court in writing. Then you should send the complaint by registered mail with acknowledgment of receipt or fax. It also applies to the lawsuit that it is not possible to submit it by email. We also offer a free sample letter for this, which you can download and use.
You can also have the complaint filed with the registry of the social court. Here you will be helped with the formulation and you can discuss the lawsuit.
You should enclose the following documents with the lawsuit or bring them to the court: It is beneficial if you already name or enclose evidence (e.g. witnesses, letters or doctor's certificates, other documents, etc.). So that the court can form an opinion, you should also enclose a copy of the contested decision and the notice of objection.
However, you can also submit reasons later if you do not have enough time within the deadline. You can also get legal advice on this.
In the vast majority of cases, court costs do not arise before the social court. If the procedure ends in favor of the person in need of care, their legal fees will be covered by the care fund. Plaintiffs can also check with the help of their lawyer whether the competent court is granting them legal aid.
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