Appealing a refusal to fund treatment: deadlines, structure of the complaint and court

What can be appealed, and against whom?

Under the General Administrative Code, an administrative body is any state or municipal body or institution, legal entity of public law and any other person exercising public-law powers on the basis of legislation. In funding cases this is usually the National Health Agency, the Social Service Agency, the Ministry or a municipal City Hall.

An interested party may appeal:

• a refusal to grant an application, in full or in part, including approval of a smaller amount than requested;
• an action not connected with issuing an act, for example refusing to accept an application;
• silence: under Article 177 of the Code, missing the deadline for issuing an act counts as a refusal and is appealed in the same way.

An interim decision taken during the proceedings cannot be appealed separately unless it violates your right on its own. It also matters who your dispute is with: a refusal by a private insurance company or a clinic is not an administrative act and is resolved by other means, which we cover on the insurance disputes and medical disputes pages.

Before you appeal: ask for a written, reasoned refusal

A verbal "not funded" is not an act for which an appeal deadline runs. Under Article 53 of the Code, an individual act issued in writing must contain written reasons and cite the provision on which it is based, and in a discretionary decision, all material facts. Under Article 52, the act must state with which body, at what address and within what time it can be appealed.

These two requirements often become grounds for a complaint in themselves. If the refusal says only "does not meet the programme conditions", the reasoning is insufficient. And if the body based its refusal on information about you that differs from what you submitted, under Article 101 it should have heard your view before refusing, except in emergencies.

If you do not have the case materials, request them as public information: a public institution must provide it immediately or within 10 days at most, and cannot charge you anything except for copies. Your own application, its registration number, the assessment report or an extract from the commission minutes are essential for preparing a complaint.

What deadlines apply?

GAC: General Administrative Code of Georgia; ACP: Administrative Procedure Code of Georgia. A programme's rules may set their own deadline: the Universal Healthcare approval letter, for example, is issued within 60 calendar days of the application.

If you missed the complaint deadline because of force majeure or another good reason, it must be restored; justify this request in the complaint itself and back it up with a document, for example a hospital certificate. As a rule, the body does not review a complaint filed late, so count the deadline yourself from the day of service and do not wait until the last days.

How do you write an administrative complaint?

A complaint is made in writing. Article 181 of the Code lists its mandatory elements, and in practice they are usually set out in this order:

1. Addressee and complainant

   The name of the body with which you are filing the complaint, and your name and address. If you are acting on behalf of the patient, state the basis of your representation and attach the power of attorney.

2. The act under appeal

   Which act of which body you are appealing: its title, number, date and date of service. If you were handed the act, be sure to attach a copy.

3. The request

   State precisely what you are asking for: that the act be declared void and a new act issued granting funding, in full or for a specific amount.

4. Circumstances and arguments

   The facts on which your request is based, and why the refusal is wrong: a circumstance not examined, the wrong category, insufficient reasoning, a breach of your right to present your view. You can also cite the law and provisions of the European Convention on Human Rights.

5. List of enclosures

   A numbered list: the act under appeal, Form IV-100/a, the cost estimate, a new medical opinion, answers from other sources. Attach any foreign-language document together with a Georgian translation.

No state duty or other charge is imposed for reviewing the complaint. Each party covers its own costs, and if the complaint is upheld, the body reimburses your lawyer's costs only if you are unable to pay. We prepare translations of foreign documents under the rules for court and legal document translation.

Who reviews the complaint, and how?

As a general rule, the complaint is reviewed by the body that issued the act, if it has an official superior to the official or structural unit that issued it. If the act was issued by the head of the body, the complaint is reviewed by the higher body. A particular programme may have a special rule, so check the addressee against the appeal body named in the act.

Within 5 days of registration, a copy of the complaint is sent to the body that issued the act, which submits the case materials and a written opinion within 5 days. If an oral hearing is held, you must be notified at least 5 days in advance, and you should submit additional documents and your views no later than 5 days before the hearing. The complaint is reviewed without a hearing when all parties agree or when there are grounds for refusing to review it.

There are three possible outcomes: the complaint is upheld, partly upheld or rejected, and this decision is itself an individual administrative act. The body may amend the act under appeal or declare it void or no longer in force.

What should you do when the agency is silent?

Silence is the most dangerous situation in funding cases, because the family waits for an answer while time for treatment runs out. The law is clear here: if an administrative body misses the deadline for issuing an act, this counts as a refusal to issue it and is appealed in the same way as a written refusal. In this case no appeal deadline applies, so fear of missing a deadline should not hold you back.

1. Work out the deadline. From the registration date of your application, count the general one-month deadline or the programme's special deadline, for example the 60 days for a Universal Healthcare approval letter.
2. Ask for information. Quoting the registration number, ask in writing what stage the proceedings are at and whether the body has decided to extend the deadline.
3. File a complaint. If the deadline has been missed, ask in the complaint that the superior official or body order the act to be issued or take the decision itself.
4. Plan B. If the time limit for reviewing the complaint has also passed, you can file a lawsuit in court asking for the act to be issued.

When and how should you go to court?

Under the Administrative Procedure Code, the court will not accept a lawsuit against an administrative body if the claimant has not used the one-time opportunity to file an administrative complaint, except in cases provided for by law. In other words, a complaint is usually a mandatory first step. The type of lawsuit depends on your goal:

• Declaring the act void (Article 22), when the refusal directly and immediately restricts your right;
• An order to issue an act (Article 23), when you want the court to order the body to issue a funding act. If the refusal is unlawful or the deadline was missed, the court orders the body to issue the act and, at your request, sets a deadline for it; if the matter is not discretionary and needs no further examination, the court can settle it itself;
• Performing an action (Article 24), when the case concerns a specific action rather than an act.

In treatment cases the most important tool is the interim order: on application, even before a lawsuit is filed, the court can issue an interim order when a change in the current situation would prevent or seriously hinder the exercise of a right. For this you will need a doctor's opinion showing why treatment cannot wait for the court dispute to end. We provide court representation and document preparation as part of our funding search service.

Complaint or fresh application: which is better?

A dispute is not always necessary. Under Article 102, a fresh application on the same matter is accepted if the factual or legal situation has changed in your favour, or if new circumstances or evidence have emerged that would lead to a more favourable decision. If the refusal was based on a missing document or an incomplete Form 100, applying again with a corrected package is often faster than a complaint review; and a new medical opinion is new evidence in itself.

A sensible strategy is often a combination of both routes: a complaint to protect the deadline, and alternative sources in parallel. Which body might refuse what, and which document fixes it, is described in detail in the guides to the referral programme, Universal Healthcare and municipal assistance, while for a dispute about your social rating score the social status guide will help.

Frequently asked questions about appealing a refusal