Retrospective CHC Appeals

Has the opportunity to apply for retrospective Continuing Healthcare funding been removed?

Many people living in nursing home accommodation may have inappropriately paid for some or all of their care fees.  The government imposed a deadline for lodging retrospective claims for reimbursement of care fees where a person should have been in receipt of Continuing Healthcare.  The periods for these deadlines are detailed below:

• For periods of care between 1^st April 2004 and 31^st March 2011, the deadline for claims was closed on 30^th September 2012.
• The government imposed a further deadline on 31^st March 2013.  e.g. for periods of care from 1^st April 2011 and 31^st March 2012.

Where a deadline has been passed, no further claims for those time periods will be accepted unless it can be shown that there are exceptional circumstances.

At the time the deadlines was announced, Continuing Healthcare teams were inundated with applications for retrospective Continuing Healthcare assessments where their relatives were still in care or had passed away.  Due to the number of claims received, they gave indications that these cases were likely to take two to three years to be reviewed and considered.  This would appear to have been an accurate forecast.  Having heard very little from the appeals teams for almost two years, we are beginning to see renewed activity in most cases. 

Families who have lodged appeals within the deadlines are likely to be contacted in the near future.  These extended delays may cause applicants problems where the availability of evidence in support of applications may be in short supply.  Often this involves collecting information from various sources including hospital records, GP notes and care home paperwork to ensure that a claim will be viewed in the best possible light.

Many residents and their representatives are unaware of these deadlines and miss the opportunity to seek retrospective reimbursement of care fees for periods when the resident may have been eligible for full funding by the NHS.

These claims can arise where a person was not assessed at all or the review assessment was missed.  Claims can also arise however, where the process for the assessment was not followed accurately.

Eligibility for Continuing Healthcare funding should be initially reviewed after a three month period and annually thereafter.  In many locations, residents ‘routine reviews’ have not been undertaken in a timely manner and it is not unusual for a period of 18 months to have lapsed between reviews.  During these periods residents may have fallen into (and in some cases back out of) CHC eligibility without those periods of intense needs ever having been recognised.  Although the resident may become eligible for a relatively short period of time intense nursing care costs are extremely high and this could equate to many thousands of pounds in care charges. 

Even after a resident’s death the question arises whether the executors of their estate ought to consider these issues.  It may be prudent for them to seek a review of care needs to see whether the criteria for Continuing Healthcare funding may have been met by the deceased during care periods just before the deceased passed away, thus maximising the deceased’s estate.  Beneficiaries of estates increasingly question whether the executors have discharged their responsibilities in realising the full value of the deceased’s estate.  Similarly attorneys are being questioned more frequently to assess whether their duties during the deceased’s lifetime were carried out effectively and particularly whether timely advice was sought in respect of the care costs. 

At Sydney Mitchell we have extensive experience supporting families through Continuing Healthcare assessments and appeals.  Within the team we employ a Community Psychiatric Nurse who previously worked within the NHS CHC service as an assessor.  He also undertook appeals and retrospective assessments. 

We feel that we are in a unique position to assist and support residents, their families, attorneys or executors in all aspects of the Continuing Healthcare process and seeking to ensure that where a person has needs which meet the CHC criteria, that funding is obtained.

If you would like help or guidance with any Continuing Health Care matters, please speak to Tracy Creed on 0121 746 3300, email t.creed@sydneymitchell.co.uk or complete our online enquiry form and we will be only too pleased to help you with this complex area.