Rosie, This is a very long reply but stick with it!
If you look at your monthly statement from l'Assurance Maladie you will see in the "montant versé" column not only the sum they have repaid but also, on the line below, a heading "participation forfaitaire". This was introduced some time back and is basically a sneaky way of reducing what they refund. Usually this sum, which can vary widely -- on my last two statements the range is 50 centimes to 4 euros -- is deducted immediately. So if, for example, the cost of the medication was 19 Euros, and it is refunded at 30 per cent, they will technically refund you 5.70 euros. But this is reduced by the "participation forfaitaire" which in this case (taken from my own records) was 2.50 euros. So they actually pay you 3.20 euros. And the difference is not, so far as I am aware, refunded by the mutuelles.
So far, so simple. However, as soon as "tiers payant" gets involved -- i.e. you don't pay the pharmacie for your prescription and they claim the cost directly from the sécu -- things get complicated. They don't pay the "participation forfaitaire", you do. So in these cases, instead of "participation forfaitaire" you will see "franchise à retenir". This means that you owe the sécu the sum on that line. These "debts" are added up until such time as you get a refund that is paid directly to you. They then deduct the total debt from that refund. Over time it can be quite a large sum.
I have this problem constantly as not only do I have "tiers payant", but most of my medical expenses are refunded 100 per cent by the sécu. So the occasions when I actually pay for something for which they then refund me directly are few and far between and I quickly accumulate a debt mountain.
It is very difficult to keep a check on how much you owe them and whether they are deducting the right amount, but you can try adding up the "franchises à retenir" to see if the figures gel.
I just noticed on my latest statement the following message:
"Pour les prestations figurant ci-après vous n'avez pas réglé directement votre professionnel, les participations forfaitaires ou les franchises n'ont donc pas été payées. C'est pourquoi elles sont prélevées de manière différée sur ce remboursement".
The statement then lists a total of 5.50 euros that have been deducted.
We have CPAM and mutuelle cover. Until relatively recently there was no problem, but now we are only getting a proportion of costs from the CPAM and nowhere near 70%, say, for visits to our Medecin traitant.
I queried this and got the following response, which I don't understand:
Je vous informe que la consultation du 20/07/2012 a bien été remboursée par votre caisse d'Assurance Maladie, le 24/07/12 pour un montant de 15.10 euros.
Cependant, sur ce remboursement, nous avons retenu 12.50 euros de franchises médicales et de participations forfaitaires passées qui demeuraient, jusqu'à cette heure, en instance de récupération et qui correspondent à des soins pour lesquels vous n'aviez pas fait l'avance des frais.
Ceci explique la somme de 2.60 euros que vous avez vue depuis votre compte, sur www.ameli.fr, ou sur votre compte bancaire.
Je vous rappelle que vous pouvez accéder au suivi annuel des franchises et participations forfaitaires retenues dans votre Compte, sur ameli.fr.
I tried the English helpline, but they said they didn't get involved in individual cases...ask at the local CPAM.
I would, but I wish I understood better what has happened, first! Has this happened to anyone else, and what did you do, if so?
I am lucky as my mutuelle is included with my job !!! Before this we paid over 130€ a month for the 5 of us !!!!! Now its so much easier, it seems that nowadays most companies will pay your mutuelle in France
May be worth talking to your employer
Hope you get well soon Andrew, those ribs are gonna be painful for a while, I broke only 1 last year, I cant imagine the pain of 3 !!!!!!!!!!!!!!!! Hugs
Too right, the physio actually said that she is not as sceptical as the medic and that from her point of view I am not doing badly. We'll cope with the rest as it happens. That helps. Two months slow reduction and drugs gone is gold though. I have another IRM, but my shoulder this time, on Monday morning. See the surgeon again in two weeks. I am planning to get everything moved to Bordeaux which is a fantastic hospital bcause I am fed up of Bergerac, have proper specialist there and might as well have any necessray neurology dealt with under the same 'roof'.
Jane, keep your chin up too. Never had a problem like asthma but have seen my nephew in paroxisms with it. Like you, I am grateful for the good but fortunately have unlimited patience and never give up, which both help. Thanks for the 'congrats' as I read it too.
Thanks Jane, you're right, it's very difficult when you're used to be so active to then be reliant on others for everything! but a good experience too. Fingers crossed for your scan and getting the asthma under control - a trip up into the Alpes for nice dry air...?
@Andrew & Brian, learning to be still and depend upon others is a "life lesson". Unfortunately, I had to learn it in my late teens and early twenties, but it has stood me in good stead.
You know the old saying that it is as good to receive as it is to give, well this is where it really comes into play. It is a hard lesson, but it makes you a more understanding and tolerant person and you can always give back when you have the chance.
It is good to hear that you are now mobile again Brian and that there is no epilepsy.
I hope you both continue to make good progress.
I have to have another scan on the 20th in Macon, but I am feeling better, although the asthma is still not under total control.
Glad you're ok to drive again and off drugs, Brian but the rest sounds a nightmare. I would say "chin up and keep taking the tablets" but will go for "chin up and keep going with the physio" ;-)
OK, bad news is that I have capsulitis, damaged or broken tendons and a high schance of necrosis (which causes arthrities) and may need a shoulder joint replacment although I am considered a bit young (I like, BUT...) for that because of the lifetime of the prosthetic. Just one accident does all of that.
The good news is that I had a scan yesterday and with the other scans it appears that I do not have epilepsy as they thought. The reason for my 'accident' (I still think I simply fell out of bed) and the couple of seizures that I had after might have been brought about by the strong painkillers because I have a strong drug aversion but also high tolerance and require big doses. So, slowly off the anti-convulsants and driving is now 100% OK. Yahooo!
Hope you are on the road to recovery now Andrew :)
You're absolutely right about the Mutuelle, I know as the premiums increase it's easier to think 'why do I pay out so much?' but I've known lots of people have accidents and it's totally needed. My mum was knocked over - years of therapy, my friend, like yourself, a keen cyclist, came head first off his bike & landed on his neck - extremely lucky that he is here still but does have to do exercises every day to protect his neck from further damage & I had a neighbour who fell off a terrace (accident not drunk) and has permanent neck injury, head injury & eyesight problems all requiring ongoing care. If these had been in France and they hadn't had insurance can you imagine the size of the hospital & ongoing care bills? Especially when they couldn't work - beyond the statutory sick period.
Everyone should insure against accident as well as illness - the Mutelle is the way to go - like you said there are options for those on a low income, but going without insurance shouldn't be one of those options.