Hand transplant in the US, she claims almost a million euros from health insurance

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Return to court for social security. The Paris Primary Health Insurance Fund (CPAM) was first sentenced to refund more than € 664,000 to Laura Nataf for a hand transplant made in the United States in 2016, but will not pay € 1. .. However, the patient’s lawyer is assertive. The 34-year-old woman was suffering from a “refusal of care” in France. A lawyer who decided to repair her client’s damage increased her appeal by requesting an additional € 322,507 refund for her dosing and hospitalization costs. The hearing will be held on Thursday, June 23, and if Laura Nataf wins her proceedings, social security may be ordered to pay the patient € 986,507.

It was in 2007 that Laura Nataf, then 19 years old, suffered from sepsis while doing an internship in Spain as part of her studies at a hotel. After being placed in her artificial coma and returning to France, she awoke three weeks later with her forearms and legs amputated. She is then hospitalized for 5 weeks, after which she is transferred to a rehabilitation center where she adapts to her leg and arm prostheses. “But I missed her hand,” says Laura Nataf, who turned her daily life upside down. “She is especially with the help of caregivers to take a shower, eat, and protect her privacy, but young girls are increasingly less tolerant of this addiction and the gaze of others,” her lawyer said. , MeSellam Benisty continues.

After seeing a documentary about a transplant, Laura Nataf decides to find her hand. She contacted Professor Laurent Lantieri, who heads plastic surgery, reconstructive surgery and cosmetic surgery at the European Hospital Georges Pompidou Hospital (HEGP) in Paris. “Together, they started a management procedure so that she could benefit from a double transplant of her forearms and hands, and she was 23 years old and had numerous health checks before this double transplant. I will receive it, “explains Me Sellam Benisty.

Removed from national transplant waiting list

The situation started pretty well as the Regional Health Agency (ARS) gave a green light to the transplant in 2012. Later, Laura Nataf was put on the national waiting list in February 2013. However, the approval from ARS was not renewed in 2014. .. In the United States, we especially thank Professor Scott Levin, who works in the same field at the Penn Medical Hospital in Philadelphia, “explains Laura Nataf’s lawyer. Your doctor will be responsible for managing your health insurance reimbursement.

And, for good reason, Article R160-4 of the Social Security Act provides for the possibility of a lump-sum refund under health insurance for patients being treated abroad, which cannot be provided in France. However, provided that the patient clearly demonstrates that he / she is not able to receive appropriate care for his / her condition on French territory and that the medical adviser has given a favorable opinion.

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Fate has plagued Laura Nataf when she received a letter of refusal to care abroad from CPAM in Paris on February 10, 2016. “Mediocre, incomplete and concise decisions […] Required without the written opinion of the organization’s medical advisor, not recommended by AR (confirmation of receipt, editor’s memo), unsigned, and lacking required information (deadlines and remedies) “Me Sellam-Benisty points out. Laura Natuff is in the process of being removed from the national transplant list.

Words against words?

Laura Nataf will undergo a double transplant in Philadelphia on the night of August 22-23. And a year later, an American hospital asked him to pay an invoice of $ 1,132,337.05. This is equivalent to € 1,056,810.17 in the euro of 2017. “According to the provisions of the law, she first seized the Social Security Friendly Appeals Commission (CRA) on March 28, 2018, but to date she has not responded to her request and has since been the Social Security Affairs Court ( TASS) On April 30, 2018, his lawyer ordered the cancellation of his decision to refuse compensation for his surgery in the United States and the reimbursement of medical and medical costs incurred by the double transplant of Paris CPAM. On July 12, 2021, a court in Paris ordered CPAM in Paris to pay a portion of its costs, $ 765,851.05 in reimbursement of approximately € 664,000.

As part of that, Paris CPAM is appealing for a decision. According to Laura Nataf’s lawyer, the organization supports her case by accusing the young woman of seizing CRA and TASS at the same time and not leaving time for the Commission to respond. CPAM also opposes patients with a two-year prescription against the February 10, 2016 refusal of care. “If you raise a social security dispute, you actually have to act for two years. However, the deadline for the CRA decision never started to be enforced. The February 10, 2016 refusal decision was sent by registered mail. It is irregular because it has not been submitted. It does not mention deadlines or means of appeal, is not signed, and is not accompanied by a written and grounded medical opinion from a social security medical adviser. , The appeal is acceptable, “continues Laura Nataf’s lawyer.

CPAM in Paris, contacted by Capital, details its line of defense. She specifies: [la] Request for prior agreement [de Laura Nataf] Regarding her care coverage in the United States, which was introduced at the end of 2015, Cnam’s chief physician (National Health Insurance Fund, editor’s note) worked with the ministry and biomedical institutions to give Nataf the same kind of hands and forearms on both sides. An experimental program open to the Hospice Sibiles Deligon on Transplantation. This would have given him the necessary care and coverage guarantees in France. CPAM then considers it justified to refuse her responsibility because Laura Nataf “did not choose to use this option.”

However, the elements mentioned by CPAM would not have been directed directly at the patient. “Social security disguised reality when reading a letter exchanged between Health Insurance, the Biomedical Agency, AP-HP, and Professor Lantieri between February 4, 2016 and February 15, 2018. I realized I was doing it, “accuses Laura Nataf’s lawyer.

“I understand that everything is in the project stage, nothing is voted on, and nothing is subsidized,” MeSellam Benisty adds, if the solution proposed in Lyon could be a patient alternative. .. Obviously, if Laura accepted this option, she would have been able to wait longer than she expected for her hands and forearms to be transplanted. In addition, “Assurance Maladie does not omit the fact that Laura Nataf was removed from the national transplant waiting list in February 2016 and therefore cannot benefit from alternative solutions, if possible. ! ”, Points out MeSellam Benisty.

According to Laura Nataf’s lawyer, the appeals hearing will be held tomorrow, Thursday, June 23, but the verdict will not be submitted for several weeks. “I hope that justice will do the job to the end and we will win this case,” she confesses to a patient who believes her “rights have been violated.” The person who realized his dream of having a child at the beginning of the year wants to finally turn the page and concentrate on her new life as a mother.