Claiming back the charges of nursing and care home fees

Those families that have a close relative in a residential care home due to physical or mental health conditions could be eligible to have their care home fees settled from the NHS and may also be allowed to get back those fees which have previously been paid for.

The program, called NHS Continuing Healthcare is free for those entitled to it and can be provided within a patient's home or care home. If that person's primary need is one of health then they may qualify, though the NHS also assesses people by technique of four indicators:

• Nature - the type of condition or treatment required.


• Complexity - problems that interact, leading them to be tough to manage or control.


• Intensity - a combination of needs that need regular interventions.


• Unpredictability - unpredicted changes in that person's affliction.

The continuing healthcare in the form of medical bills and residential care necessities should be offered to those who have medical needs that are seen as being "complex and unstable" and they include sufferers from conditions including Alzheimer's and senile dementia. Nevertheless, it would appear that there are differences in the way that health authorities classify such conditions. Some see them as "social factors" with other people arguing they are medical conditions. So, those health authorities tending to prefer the former would be more likely to refuse to set aside funds for sufferers of Alzheimer's and dementia within their region.

A few still see healthcare as a means-based issue and in some scenarios it can be. For those in a care home that do not qualify for NHS continuing healthcare, should they have over £23,000 in funds, which includes the need for that person's home then they shall be assessed to be able to meet the total costs of their proper care. For the people with capital somewhere between £14,000 and £23,000 then they will need to contribute a part of their care costs, while those whose money falls below £14,000 can get their healthcare costs covered, although earnings from pensions and benefits has to be paid towards those care fees.

For individuals who meet the criteria within the NHS continuing healthcare the above figures are irrelevant because they will be entitled to 100 % funding. However, as has been experienced by many throughout the country, the toughest task is to persuade the local PCT or health authority that the person concerned is really qualified.

Cases

The case of Hilda Atkinson is frequently referenced when viewing NHS Continuing Healthcare. She was afflicted with dementia and her family members battled a lengthy battle to try and persuade her local primary care trust, Plymouth Teaching PCT, that she was in need of 24-hour nursing care as opposed to "social care" for which she would be charged.

The case was decided in 2007 in the High Court in London and then the PCT consented to pay out £43,000 to cover the expenses of her medical health care in between January 2004 and July 2007 along with agreeing to pay for her charges in the future. Her lawyers criticised the stance of the PCT as "unlawful and wholly unreasonable".

In 2009 the family of Judith Roe, who was diagnosed with Alzheimer's, triumphed in a legal fight to reclaim £100,000 in care home charges after NHS Worcestershire had refused to fund her case, declaring that her condition was social instead of health-related. Their decision meant that Mrs Roe has to sell her house to fund the £600-a-week nursing home fees and resulted in a five-year fight between her family along with the NHS.

Mrs Roe's son firmly criticised the local PCT and said: "I want anyone else going through a similar experience to know they may be entitled to care. Even if they're being told they're not entitled, they should fight for it. With us, they made a mistake. They did not carry out their duties properly."

In a other case last year, the family of Leslie Terry retrieved nursing home fees which should have already been paid for through the NHS as part of continuous healthcare. The family of Mr Terry, who is affected by Alzheimer's disease, at first had to pay the £3,500 a month for his long-term nursing care and had not been told of the continuous healthcare programme. His family also highlighted the importance to families in a comparable predicament, of obtaining all available information to avoid being placed into a similar position.

Help at hand

For many who assume that a member of family has actually been wrongly evaluated, and that this evaluation took place before October 2007, then their first act would be to make contact with a social worker, health practitioner or maybe even an individual at the primary care trust to inquire about an ongoing care review or possibly a retrospective assessment dating back to when the relative was first admitted to the nursing home.

The family member involved can reclaim fees retrospectively even if the person involved no more lives at home. In England claims can be made for care home fees from April 2004 onwards.

For the people unsatisfied with a decision that's been made, the first course of action is to try to get an assessment the decision by the original decision making body, through a written appeal. Additional proof to aid their claim can be gathered and the case presented to the panel to review yet again.

If a relative remains disappointed after that stage they could seek an independent review by the local strategic health authority.

If you would like to know more about how to reclaim care home fees, visit our website for more information www.theclaimsconnection.co.uk