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Hampshire woman successfully appeals care home fees paid on behalf of husband

29th April 2016

A Hampshire woman who has retrospectively recovered the care home fees paid on behalf of her husband after being told he was ineligible for NHS Continuing Care is encouraging other local families to challenge decisions about care earlier.

Marianne Norman of Holbury in the New Forest says that despite being advised by hospital staff that her husband John would qualify for NHS Continuing Healthcare, he was refused assistance after an assessment of his health care needs.

Marianne explains: “In hindsight when John was denied this, I should have sought professional advice straight away, as being able to secure NHS Continuing Care can make a huge difference to your finances and both yours and your loved one’s future. Unfortunately I didn’t realise that decisions like this could be challenged.”

Over the course of 2012 and 2013, John Norman was admitted into hospital twice, initially with a suspected pancreatic cancer when hospital staff noticed that he appeared confused and then again when he was diagnosed with a burst gastric ulcer. On this occasion Marianne was advised that there was a fifty per cent chance John would make it through the treatment.

John was placed into an induced coma and after he awoke Marianne says he was never the same again. He was eventually diagnosed with limbic encephalitis; a virus that attacks the parts of the brain that control speech, memory and movement.

Due to John’s high level of care needs, Marianne was advised that she may have to consider a care home as the best environment to support him. 

Before discharge, John was assessed to see if he was eligible for NHS Continuing Care but his health needs were not considered high enough to entitle him to NHS Continuing Care.

The care home fees where Marianne had found a suitable place for John were just over £5,000 a month, which Marianne would now have to pay herself. She used a combination of savings and John’s private pension lump sums which became payable just before he got ill. They had also purchased a new motor home to enjoy during their retirement, but Marianne had to sell this to pay for John’s care fees.

After consulting with a charity about John’s medical condition in December 2013, Marianne was advised to challenge John’s entitlement to NHS Continuing Care and was referred to Paula Barnes of Moore Blatch solicitors.

Through Moore Blatch, Marianne successfully overturned the original decision about NHS Continuing Care. The panel making the decision visited John at his care home with Marianne and Moore Blatch and agreed that the level of John’s health needs would entitle him to NHS Continuing Care.

Following this decision the NHS took over funding John’s monthly care home fees and Marianne was reimbursed the fees which she had paid during June - November 2014 plus interest, but for the other outstanding fees she had to be considered by a separate retrospective panel.

Moore Blatch collated the medical and care home records for the period that still had to be reviewed (from September 2013 to June 2014). After considering the evidence available, the panel agreed with Moore Blatch’s assertion that John did have a high level of health care needs which would entitle him to NHS Continuing Care during this time. Marianne was reimbursed all the care fees she had paid from the date John was admitted to the care home, together with interest.

Paula comments: “Unfortunately there have been an incredible amount of cases where people have been entitled to NHS Continuing Care, but for some reason on assessment have failed to secure this support. Awareness of NHS Continuing Care and how this can help families is also very low and this is reflected in statistics all over the country, with a significant gap in the numbers between those claiming and those entitled.

“We would encourage people to get legal advice whilst going through the assessment process; this will help them to put their best case forward and may prove more timely than having to appeal a decision that has already been made.”

What is NHS Continuing Care?

NHS Continuing Healthcare is a complete package of ongoing care arranged and funded by the NHS for individuals found to have significant, ongoing healthcare needs as a result of an accident, disability or illness.

If you are living in a care home, the NHS will make a contract with your provider to pay the fees in full, including accommodation and care.

If you receive care at home, the NHS will fund an appropriate package of provision for your health and personal care needs to suit your circumstances.

What are the difficulties around NHS Continuing Care?

As in John Norman’s case – people have been wrongly denied NHS Continuing Care. The assessment process often requires experience to navigate it correctly.

There can be significant delays recouping retrospective fees and getting through the assessment process.

In John’s case, his assessment occurred before discharge from hospital, as Paula explains, this can sometimes affect outcome: “Sometimes in a hospital setting a person’s needs can be assessed to be lower, because they may be managed or if they are less mobile, they do not require as much support. Ideally this should not occur or affect the outcome of an assessment, but sadly it sometimes does.”

There are also ways of reducing delays faced by many people – in certain circumstances Moore Blatch has been able to agree a specific procedure on behalf of clients, helping to collate the essential documents needed in specific cases – so that the Clinical Commissioning Group only have to make the final assessment.  

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