Grafting her hands in the United States, she claims almost one million euros from Health Insurance

Return to court for the Secu. Sentenced in the 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 Caisse primaire d’Assurance maladie (CPAM) in Paris does not intend to pay a single euro. But the patient’s lawyer is categorical: this woman, now 34 years old, has suffered a “refusal of care” in France. Determined to repair the damage to her client, the lawyer increased the bill on appeal by requesting reimbursement of an additional 322,507 euros, in respect of medication and hospital stay expenses. The hearing will be held on Thursday, June 23, if Laura Nataf wins, the Secu could be ordered to pay 986,507 euros to the patient.

It was in 2007 that 19-year-old Laura Nataf suffered a seizure while on internship in Spain as part of her hospitality studies. Placed under an artificial coma and repatriated to France, she will wake up three weeks later with both forearms and legs amputated. She will then be hospitalized for five weeks and then transferred to a rehab center for three months, where she will be accommodated with 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 being cared for by a caregiver, especially for showering, eating, intimacy, but the girl is less and less able to cope with this addiction and the gaze of others,” said Sellam Benisty, a lawyer.

It was after watching a documentary on transplants that Laura Nataf decided to get her hands back. Contact Professor Laurent Lantieri, who heads the Department of Reconstructive and Aesthetic Plastic Surgery at the Hôpital Européen George Pompidou (HEGP) in Paris. “Together, they started administrative procedures so that she could benefit from a double forearm and hand transplant, and at the age of 23 she underwent many pre-transplant medical examinations, which remains a surgical procedure. quite exceptional character. ”, details Me Sellam Benisty.

Deleted from the National Transplant Waiting List

Things are starting to get pretty good 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 of the ARS does not however, it was not renewed in 2014. „Faced with the absolute failure to give his young patient a double transplant of his forearms and hands in France, Professor Laurent Lantieri was then forced to turn to his counterparts. . in the United States and, more specifically, to Professor Scott Levin, who operates in the same discipline at the Penn Medicine Hospital in Philadelphia, ”explains lawyer Laura Nataf. The doctor deals with the administrative steps for an award in charge of assistance for health insurance.

And for good reason, Article R160-4 of the Social Security Code provides for the possibility, for patients receiving care abroad who cannot be provided in France, of the flat-rate coverage by the Health Insurance. Provided that the patient establishes well that he cannot receive on the French territory the care appropriate to his condition and that the consulting physician gives a favorable opinion.

The fate of Laura Nataf on February 10, 2016, she received a letter of denial of care abroad from the CPAM in Paris. “It simply came to our notice then […] without the written opinion of the Physician Council of the Agency, however mandatory, not recommended with AR (acknowledgment of receipt ed.), unsigned, without mandatory information (deadlines and remedies) ”, points out Mr. Sellam-Benisty. Laura Nataf is in a foulée removed from the national graft list.

Word for word?

Laura Nataf will still receive her double transplant in Philadelphia on the night of August 22-23. And, a year later, the American hospital asks him to pay the bill of $ 1,132,337.05, or the equivalent in euros in 2017 of 1,056,810.17 euros. “In accordance with the law, it first appeals to the Social Security Amicable Appeals Commission (CRA) on March 28, 2018, but no answer will ever be given to its request to date. Affaires de Sécurité Sociale (TASS) on 30 April 2018, seeking the annulment of the decision to refuse the award for operation in the United States and ordering CPAM de Paris to reimburse him for his medical and paramedical expenses incurred by his double transplant “, Says his lawyer. On July 12, 2021, the Paris Judicial Court ordered the Paris CPAM to pay $ 765,851.05 in reimbursement of part of its costs, or about 664,000 euros.

For its part, the CPAM of Paris is appealing the decision. According to Laura Nataf’s lawyer, the organization will support her appeal by blaming the young woman for seizing the CRA and the TASS at the same time and therefore failing to allow the Commission time to respond. The CPAM also opposes the patient’s two-year statute of limitations for acting against the refusal of care on February 10, 2016. “When a security appeal is filed, you do have two years to act. However, the deadline for the CRA’s decision never began to run. The refusal decision of February 10, 2016 is irregular because it was not sent by registered letter. It does not mention the time limits and remedies, it is not signed and is not accompanied by any written and motivated medical advice from the Social Security doctor. The appeal is therefore admissible, ”said Laura Nataf’s lawyer.

Contacted with Capital, at CPAM in Paris and more on the line of defense. She states that in response to [la] request for prior agreement [de Laura Nataf] for the care of her care in the United States, introduced at the end of 2015, the chief physician of the Cnam (National Health Insurance Fund, ed.), in liaison with the Department and the Biomedicine Agency, led Ms. Nataf towards an experimental program open to the Civil Hospices of Lyon on the bilateral allograft of hands and forearms, which would have made it possible to obtain the necessary care in France and the assurance of a care ”. The CPAM then estimates that the refusal to take charge is motivated by the fact that Laura Nataf “did not make the choice to resort to this option”.

Several elements evoked by CPAM were not directly addressed to the patient. “It turns out that when reading the letters exchanged between the Health Insurance, the Biomedicine Agency, the AP-HP and Professor Lantieri, between February 4, 2016 and February 15, 2018, the Social Security disguised the reality, ”said Laura Nataf’s lawyer.

If the solution proposed in Lyon could be an alternative for the patient, “we understand that everything is in the draft state, you did not vote for us, nothing is subsidized,” said Me Sellam Benisty. Clearly, if Laura had accepted this option, she could have attended for a long time to become a grafter les mains et avant-bras. Moreover, “the Health Insurance omits the circumstance that Laura Nataf was in any case deleted from the National Transplant Waiting List in February 2016 and therefore unfit to benefit from any alternative solution even though she would have been conceivable: 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 handed down for several weeks, according to Laura Nataf’s lawyer. “I hope that justice will do its job to the end, that this appeal will be won,” said 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 finally hopes to turn the page and dedicate herself to her new life as a mom.

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