Care Objections and appeals against decisions by long-term care insurance funds

People who receive a decision from their long-term care insurance fund that rejects or insufficiently accepts an application do not have to simply accept this. For example, no care grade or too low a care grade may have been certified when applying for care benefits. In other cases, a benefit for home improvement measures or an application for respite care allowance may have them rejected. In such situations, people have the opportunity to file an objection and, if this is rejected, appeal to the Social Court.

When objecting to a decision by a long-term care insurance fund, several aspects must be considered. The objection must be submitted within one month of receiving the decision. If the decision does not provide information about the right to object and the deadline, the deadline extends to one year. 

Objections must always be made in writing and delivered in person or submitted by post (ideally as a registered letter with acknowledgment of receipt) or fax. It is not possible to submit an objection by e-mail or telephone. If necessary, the objection can also be filed by an authorized person or someone appointed by the court as a custodian. In this case, this person must prove their legitimacy by presenting a certificate of power of attorney or a certificate of appointment. Otherwise, the objection will not be deemed to have been filed lawfully and the submission period will not be stopped.

Detailed information on frequently asked questions about the deadline for objections can be obtained from the Consumer Advice Centers.

The grounds for the objection do not have to be submitted within the one-month deadline period; they can also be submitted later.

However, if the long-term care insurance fund sets a processing deadline for the grounds for the objection, this should be observed or, if a little more time is needed, extended following consultation with the long-term care insurance fund. 

The provision of grounds for an objection is optional but highly recommended in order to increase the chance of success. Depending on the type of benefits applied for, a report may have been created by the Medical Review Board within the scope of the application. If this is the case and the report is not already available, it should be requested so that the objection can be justified. Anyone with new or additional medical documents should include these with the grounds for the objection. Close collaboration with a doctor, social welfare association, care advice center or lawyer specializing in social law can increase the chance of a positive decision. 

During the objection procedure, the long-term-care insurance fund reviews its decision. Depending on the type of application, the Medical Review Board may be involved and provide a second opinion. This opinion is usually created based on the files. In some cases, an assessor may (re-)visit people. 

It is important to be well prepared for visits by assessors. The original report should be read carefully to ensure that all existing illnesses were correctly considered. People should also request all new medical documents that have come into play since the initial assessment.

Depending on the type of benefits applied for, the long-term care insurance fund needs several weeks to rule on the objection. If the objection is successful, a positive decision will be issued. This is known as a redress. If the long-term care insurance fund rejects the objection, an objection decision will be issued that terminates the out-of-court objection procedure. 

If the long-term care insurance fund rejects the application again during the objection procedure or only grants care benefits to an insufficient extent, an appeal can be submitted to the Social Court. It is particularly worth lodging an appeal if a lawyer has legally reviewed the report and determined the existence of a higher need for benefits. 

The appeal must be lodged within one month of receiving the objection decision. The decision is often issued in the form of a registered letter in a yellow envelope. The envelope shows the date on which the letter was handed over. This date should be noted down or the envelope stored as it is important for compliance with the appeal deadline. 

The appeal must be submitted in writing. E-mail submission is not permitted. Important documents for the appeal include the original decision from the long-term-care insurance fund, the objection decision and all relevant medical documents. It is advisable to seek the support of a lawyer who specializes in social law or a social welfare association.

The appeal can also be directly submitted to the Social Court’s administrative office. People can furthermore discuss their appeal with members of the office team and obtain help when formulating an application. 

People do not usually incur legal costs for an appeal unless they instruct a lawyer. If the appeal is successful, the long-term care insurance fund will cover the lawyer’s costs. Those who have few financial resources can also have a lawyer check whether the responsible court will grant them legal aid.

Further information and support can be obtained from various places. 

The Consumer Advice Center offers useful model letters that can be used as templates for objections and appeals in the event of a rejected or insufficient care grade. Depending on the federal state, it is sometimes also possible to receive custom advice on care rights.

Social welfare associations such as the Social Association of Germany (Sozialverband Deutschland (SoVD) e.V.) and care advice centers offer advice and support in relation to the objection process. 

If the legal questions are more complex or an appeal is required, it is advisable to consult a lawyer who specializes in social law.