If the Pflegegrad (care grade) is too low or has been refused altogether, you can lodge an appeal (Widerspruch). You have one month from receiving the decision to do so; a short letter is enough to begin with, and you may submit the reasons later. Many appeals lead to a better result – it is worth trying.

Details

A decision by the Pflegekasse (long-term care insurance fund) is not an unchallengeable truth but a decision based on an assessment report – and assessment reports can miss the reality. This happens particularly often with dementia, with mental illness, with fluctuating conditions and whenever the person being assessed has pulled themselves together for the appointment.

The deadline: one month

The Widerspruch (appeal) must reach the Pflegekasse within one month of notification of the decision (§ 84 Sozialgerichtsgesetz). The deadline does not start with the date on the letter but with its receipt – where a decision is sent by post it is usually deemed to have been notified on the third day after it was posted (§ 37 SGB X). So make a note of the day on which the letter was in your letterbox, ideally directly on the envelope.

If the decision does not contain the Rechtsbehelfsbelehrung (the notice explaining your right of appeal) or if that notice is wrong, the deadline is extended to one year. But do not rely on that – act within the month.

The deadline-preserving appeal

You do not need a finished set of reasons for the appeal. It is usual and permissible to lodge a fristwahrender Widerspruch (an appeal that preserves the deadline): a short letter that saves the deadline, announcing that the reasons will follow. A suggested wording:

“Dear Sir or Madam, I hereby lodge an appeal against your decision of [date], reference [number]. I will submit the reasons in due course. For this purpose, please send me the complete assessment report of the Medizinischer Dienst including all individual scores. Yours faithfully”

The appeal must be made in writing (by letter, by fax or – if the fund offers this – through its secure online portal); alternatively you can state it for the record at the Pflegekasse. Send it by recorded delivery if possible and keep a copy. A telephone call is not enough.

Checking the assessment report – this is where it is decided

On request, the Pflegekasse must send you the Pflegegutachten (assessment report). Only with it can you see where points are missing. Go through the six modules and compare each rating with everyday reality:

• Module 1 – mobility (10 %): getting up, moving from one place to another, moving around the home, climbing stairs.
• Module 2 – cognitive and communicative abilities and module 3 – behaviour and psychological problems (15 % together, the higher value counts): orientation, remembering, holding conversations; restlessness at night, a tendency to wander off, anxieties, resistance to care.
• Module 4 – self-care (40 %): washing, dressing, eating, drinking, going to the toilet, dealing with incontinence.
• Module 5 – coping with demands arising from illness and treatment (20 %): medication, dressings, injections, visits to the doctor, therapies.
• Module 6 – organising everyday life and social contacts (15 %): structuring the day, activities, maintaining contacts.

Typical errors in the report: abilities are assumed that only work when the person is prompted; the need for help at night is missing; the information comes from the person being assessed, who has played down their situation; dementia is only noted as a diagnosis but is not reflected in modules 2 and 3; aids are counted as “available” even though the person cannot use them independently.

What happens next?

Once your reasons have been received, the Pflegekasse will usually arrange a second assessment – often by a different assessor, sometimes on the basis of the files alone. Prepare for this appointment just as carefully as for the first one. You will then receive a decision on your appeal (Widerspruchsbescheid).

If the refusal stands, you can bring a claim before the Sozialgericht (social court) within one month. The proceedings are free of court fees for insured persons; a lawyer is not required. Social welfare associations represent their members in such proceedings.

What to do

1. Record the date of receipt. Note the day the letter arrived and mark the deadline in your calendar (one month).
2. Send off the deadline-preserving appeal – short, in writing, with a request for the complete assessment report. Keep a copy and proof of posting.
3. Check the assessment report module by module and mark every point that does not match everyday life.
4. Keep a Pflegetagebuch (care diary), for at least 14 days, with times of day and night-time hours. It is the strongest counter-argument.
5. Collect evidence: recent medical reports, hospital and rehabilitation discharge letters, medication plan, documentation from the care service, a statement from the GP.
6. Submit your reasons: for each disputed module write specifically which rating is wrong and why – with examples (“Mrs M. cannot wash herself; she stands in front of the washbasin and does not start unless she is prompted.”).
7. Get advice. A Pflegestützpunkt (care support point), a social welfare association or a consumer advice centre will go through your reasons with you – this considerably improves your chances of success.
8. Prepare for the second assessment as you would for the first appointment: have the person providing care present, the diary and documents ready, and describe a normal day.
9. Check the decision on your appeal. If necessary: bring a claim before the Sozialgericht within one month.

Where to get help

Nobody has to write an appeal on their own.

• Pflegestützpunkte give free, independent advice that is not tied to any provider – including on appeals. 36 locations in Berlin, and in Brandenburg in every district and independent town. Addresses: Addresses (service type “Beratungsstelle / Pflegestützpunkt”).
• Social welfare associations (such as VdK and SoVD) and the Verbraucherzentralen (consumer advice centres) in Berlin and Brandenburg help with the reasons and with court claims; social welfare associations also represent members before the Sozialgericht.
• Information evenings and care courses on applications, assessments and appeals: Events.
• To prepare for the new appointment: Checklist: preparing well for the MD assessment. If the person’s condition has deteriorated further since the decision, an application for a higher care grade is also possible instead of an appeal.