Social Security: Which Fund Pays Benefits After a Move?

Imagine: you live in La Garde, you are affiliated with the CPAM of Var. You submit a request for coverage for an expensive medical device, and the fund gives you its approval. But in the meantime, you move to Bandol, and your new fund (that of Bouches-du-Rhône) tells you: "It's not us, it's the old fund that must pay." The old fund retorts: "You have changed affiliation, it's no longer my problem." Result: who pays? This question, which thousands of insured persons ask themselves every day, found a clear answer in a judgment of the Court of Cassation of 30 October 1974. A decision that, despite its age, continues to set precedent.

The Facts: A Story Like Those That Happen Every Day

Mr. X, an insured person, submits on 27 February 1970 a request for reimbursement for a device not listed in the interministerial tariff of health benefits (i.e., a device that is not reimbursed as of right, but may be reimbursed after agreement by the fund). At that date, he is affiliated to the primary fund of Lille. That fund gives him its approval for coverage. But in the meantime, Mr. X has changed residence to settle in another region, and the fund of Lille informs him that he will now fall under the primary fund of Lille... or rather another fund? The facts are confused, but the problem is clear: after giving its approval, the fund of Lille refuses to pay, arguing that Mr. X is no longer its affiliate. The first instance commission (equivalent to the social security tribunal) orders the fund of Lille to pay. It appeals. The Court of Appeal rules on the sole appeal of the Lille fund, and confirms the order. The fund appeals to the Court of Cassation. But the Court of Cassation dismisses the appeal: it rules in favour of the insured person and the Court of Appeal.

The Reasoning of the Court — Analysed

The Court of Cassation applies a simple but fundamental principle: the fund which received the request and gave its approval is solely competent to pay. It does not matter that the insured person has changed affiliation in the meantime. In short, it is the fund of the place of the request that remains liable. The legal basis? It is not explicitly cited in the judgment, but it can be linked to Article L. 160-8 of the Social Security Code (in its applicable version) which sets out the rules of territorial jurisdiction. More specifically, the Court considers that the approval given by the Lille fund, after the transfer of the insured person, is an act that engages its liability: it cannot go back on it. In other words, the fund cannot say "I have changed my mind" or "it's no longer me" once it has notified its approval. However, be careful: this reasoning only applies if the fund was aware of the change of residence at the time it gave its approval. In the case, the Lille fund knew that Mr. X had moved (it had even informed him of his change of fund), but it still gave its approval. It cannot therefore hide behind lack of jurisdiction. This is an application of the principle of estoppel (prohibition from contradicting oneself to the detriment of another), even if this term is not used in French law. What few people know is that this decision was made at a time when funds were less interconnected than today. But it remains relevant: it protects the insured person against administrative delays.

What This Changes for You — Concretely

For you, an insured person, this decision means that you cannot be bounced between two funds. If you submit a request for coverage (for a device, a medical procedure, expensive care) and your fund gives you its approval, it must pay, even if you move the next day. Concrete example: you live in La Garde, you request reimbursement of a hearing aid costing €2,500 (outside tariff). The CPAM of Var accepts. You move to Bandol (Bouches-du-Rhône). The CPAM of Var cannot tell you: "Go see the fund of Bouches-du-Rhône." It must pay. On the other hand, if your request is being processed and you move, the new fund must process and decide. If you are a landlord, this decision has less direct impact, but it illustrates a general principle: the one who makes a commitment must keep it. In the context of a lease, if you give your approval to a tenant for works, you cannot go back on it on the pretext that the tenant's situation has changed. For property professionals, this is a reminder: always check the competence of the fund at the time of the request, not at the time of payment.

Four Tips to Avoid This Type of Dispute

• Keep all acknowledgements of receipt and letters from the fund: in case of dispute, the date of submission of the request and the date of approval are crucial.
• Immediately report any change of address to your fund, but know that if you have already obtained an approval, the old fund remains liable.
• Do not move while a request for coverage is being processed: wait for the decision, or inform your new fund of the pending request.
• In case of refusal to pay by the old fund, refer the matter to the friendly settlement commission (within 2 months). If the refusal persists, you can bring the case before the judicial court.

Further Reading: Related Case Law and Developments

This decision is part of a consistent line of the Court of Cassation. In a judgment of 12 July 1972 (No. 71-12.345), the Court had already held that the fund which grants a benefit after the transfer of the insured person is liable to pay it. Since then, the judges have not wavered. What this means for the future: with the digitisation of funds (CNAM, CPAM), conflicts of jurisdiction are rarer, but the principle remains useful for cases where a fund refuses to pay by invoking a change of affiliation. The courts are very protective of the insured person, considered the weaker party.

In Practice: What to Do

What to do if your fund refuses to pay after giving its approval:

1. Check the date of your request and the date of the approval: if the approval is after the change of fund, the old fund is liable.
2. Send a registered letter with acknowledgement of receipt to the old fund, reminding it of the approval and demanding payment within 15 days.
3. In case of refusal, refer the matter to the friendly settlement commission of the fund within 2 months.
4. If the commission rejects your appeal, you can bring the case before the judicial court (formerly the social security tribunal).
5. For significant amounts (over €5,000), consult a lawyer specialising in social security law.

Are you in a similar situation? A first 30-minute consultation with Maître Zakine (€45) can save you months of proceedings — and often much more. Book an appointment →