Health Insurance Ombudsman: how to use it?

Verified 08 February 2024 - Directorate for Legal and Administrative Information (Prime Minister)

You have filed a claim with your health insurance fund and you are not satisfied with its answer? It is possible to contact the Ombudsman free of charge. This claim must fall within its jurisdiction. The mediator is the conciliator.

All users of the general sickness insurance scheme may apply to the Ombudsman.

You can contact the Ombudsman if you are in any of the following :

  • You feel you are a victim of a discriminatory denial of care and are a beneficiary of the complementary health solidarity (C2S) or theState medical aid (AME)
  • You feel that you are the victim of a discriminatory refusal of care by a health professional who does not belong to a professional body (optician, hearing care professional, etc.)
  • You have filed a claim with the Health Insurance and this claim has not been successful.

If the matter falls within his competence, the Ombudsman will take charge of it until it is resolved. The aim is to arrive at a solution acceptable to the two parties with the explanations necessary for a good understanding.

If the case is not within his jurisdiction, the mediator will refer the case to the competent department of your health insurance fund, inform you and ensure that an appropriate response is provided.

You can enter the mediator in 2 ways: from your ameli account (web version only) or by mail addressed to your health insurance fund.

Please note

An acknowledgement of receipt of your mail is always sent to you.

Répondez aux questions successives et les réponses s’afficheront automatiquement

From your ameli account

Contact the Health Insurance Ombudsman from your ameli account

Please note

Your credit union may offer you to enter the mediator by email. It can also provide a telephone reception or by appointment. For more information, contact your cash register.

By post addressed to your health insurance fund

You write a letter on free paper using the letter template.

You send this letter to the mediator of your health insurance fund.

The Ombudsman will remind you, if necessary, of the other possible avenues of redress and the time limits still at your disposal.

Who shall I contact

Please note

Your credit union may offer you to enter the mediator by email. It can also provide a telephone reception or by appointment. For more information, contact your cash register.

The mediator considers your request: it is not intended to settle a dispute, but it establishes or re-establishes a communication between the caisse and you.

It may:

  • Explain the contested decision
  • Accompany you to find a solution acceptable to you and your cash register
  • Seek to find a compromise in your relationship with your fund.

FYI  

Mediation is not a substitute for other remedies. It does not interrupt the limitation period. It suspends (during the mediation) the time limit for appealing against the decision taken by the Health Insurance.

On the other hand, the procedure before a court ends the mediation procedure.