Return to court for Social Security. Sentenced at first instance to reimburse no less than 664,000 euros to Laura Nataf for her hand transplants performed in the United States in 2016, the Primary Health Insurance Fund (CPAM) in Paris does not intend to pay a single euro. But the patient’s lawyer is categorical: this woman, now 34, suffered a “refusal of care” in France. Determined to repair the damage of her client, the lawyer increased the bill on appeal by requesting reimbursement of an additional 322,507 euros, for medication and hospital stay costs. The hearing will be held on Thursday June 23, if Laura Nataf wins her case, Social Security could be ordered to pay 986,507 euros to the patient.
It was in 2007 that Laura Nataf, then aged 19, suffered from sepsis while she was on an internship in Spain as part of her hotel studies. Placed in an artificial coma and repatriated to France, she woke up three weeks later with both forearms and both legs amputated. She will then be hospitalized for five weeks and then transferred to a rehabilitation center for three months, where she will adapt to her leg and arm prostheses. “But I missed my hands a lot,” says Laura Nataf, whose daily life has been turned upside down. “She is assisted by a caregiver, especially to shower, to eat, for her privacy, but the young girl is less and less able to bear this dependence as well as the gaze of others”, continues her lawyer, Me Sellam Benisty.
It was after watching a documentary on transplants that Laura Nataf decided to find her hands. She contacted Professor Laurent Lantieri, who heads the Plastic, Reconstructive and Aesthetic Surgery Department at the European George Pompidou Hospital (HEGP) in Paris. “Together, they begin administrative procedures so that she can benefit from a double transplant of the forearms and hands and she undergoes, at the age of 23, numerous medical examinations prior to this double transplant, which remains a surgical intervention at quite exceptional character,” explains Me Sellam Benisty.
Removed from the national transplant waiting list
Things started rather well since the Regional Health Agency (ARS) gave the green light to the transplant in 2012. Then Laura Nataf was placed on the national waiting list in February 2013. The authorization from the ARS did not was not renewed in 2014, however. in the United States, and more particularly to Professor Scott Levin, who operates in the same discipline at Penn Medicine Hospital in Philadelphia,” explains Laura Nataf’s lawyer. The doctor takes care of the administrative procedures for the reimbursement of care by the Health Insurance.
And for good reason, article R160-4 of the social security code provides for the possibility, for patients receiving treatment abroad who cannot be provided in France, with lump-sum reimbursement by health insurance. Provided that the patient clearly establishes that he cannot receive the care appropriate to his condition on French territory and that the medical adviser gives a favorable opinion.
The fate is hounding Laura Nataf when she receives, on February 10, 2016, a letter of refusal of care abroad sent by the CPAM of Paris. “A banal, incomplete and laconic decision […] without the written opinion of the Medical Advisor of the Organization yet mandatory, not recommended with AR (acknowledgment of receipt, editor’s note), unsigned, devoid of the mandatory information (deadlines and remedies)”, points out Me Sellam-Benisty. Laura Nataf is in the process removed from the national transplant list.
Word against word?
Laura Nataf will still receive her double transplant in Philadelphia the night of August 22 to 23. And, a year later, the American hospital asks him to pay the bill of 1,132,337.05 dollars, the equivalent in euros in 2017 of 1,056,810.17 euros. “In accordance with what the law provides, she first seized the Social Security Amicable Appeal Commission (CRA) on March 28, 2018 but no answer will ever be given to her request until today, then the Court of Social Security Affairs (TASS) on April 30, 2018 in order to request the cancellation of the decision to refuse coverage of his operation in the United States and the order of the Paris CPAM to reimburse him for his medical and paramedical expenses incurred by its double transplant”, recounts his lawyer. On July 12, 2021, the Paris court ordered the Paris CPAM to pay 765,851.05 dollars in reimbursement of part of its costs, i.e. approximately 664,000 euros.
For its part, the Paris CPAM is appealing the decision. According to Laura Nataf’s lawyer, the organization will support her appeal by accusing the young woman of having seized the CRA and the TASS at the same time and therefore not having left the necessary time for the Commission to respond. The CPAM also opposes the patient with the two-year prescription to act against the refusal of care of February 10, 2016. “When you file a social security dispute, you actually have two years to act. However, the deadline for the CRA’s decision never started to run. The refusal decision of February 10, 2016 is irregular because it was not sent by registered letter. It does not mention the deadlines and the means of appeal, it is not signed and is not accompanied by any written and reasoned medical opinion from the social security medical adviser. The appeal is therefore admissible”, maintains Laura Nataf’s lawyer.
Contacted by Capital, the CPAM of Paris says more about its line of defense. She specifies that “in response to [la] request for prior agreement [de Laura Nataf] for the coverage of her care in the United States, introduced at the end of 2015, the chief physician of the Cnam (National Health Insurance Fund, editor’s note), in conjunction with the Ministry and the Biomedicine Agency, directed Ms. Nataf towards an experimental program opened at the Hospices Civiles de Lyon concerning bilateral allografts of hands and forearms, which would have enabled him to obtain the necessary care in France and the assurance of coverage”. The CPAM then considers that its refusal to take charge is justified since Laura Nataf “did not choose to use this option”.
But the elements mentioned by the CPAM would not have been directly addressed to the patient. “We realize that on reading the letters exchanged between Health Insurance, the Biomedicine Agency, the AP-HP and Professor Lantieri, between February 4, 2016 and February 15, 2018, that Social Security disguises reality”, denounces Laura Nataf’s lawyer.
If the solution proposed in Lyon could be an alternative for the patient, “we understand that everything is at the project stage, that nothing is voted on, nothing is subsidized”, adds Me Sellam Benisty. Clearly, if Laura had accepted this option, she could have waited longer than expected to have her hands and forearms transplanted. Moreover, “Assurance Maladie omits the fact that Laura Nataf was in any case removed from the National Transplant Waiting List in February 2016 and therefore unable to benefit from any alternative solution even if she would have been possible: which is not the case!”, points out Me Sellam Benisty.
The appeal hearing will be held tomorrow, Thursday June 23, but the verdict will not be rendered for several weeks, according to Laura Nataf’s lawyer. “I hope that justice will do its job to the end, that we will win this appeal”, confides the patient who believes that her “rights have been violated”. The one who realized her dream of having a child at the beginning of the year hopes to finally turn the page and devote herself to her new life as a mother.
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