Chapter 9 - Analysis – Appeals Process

There were a number of issues which suggested that the arrangements in this case did not fall neatly into one of the administrative categories for the payment of nursing home fees which were provided for by various pieces of legislation and related guidelines.

Because of the peculiar administrative and contractual arrangements involved in this particular case, it is questionable as to whether reliance on the fact that a subvention was applied for and apparently paid (although the precise audit trail for this has not been established) provided a sound basis for the rejection of the appeal.

Given the acknowledged limitations of the HRS, it was not unreasonable for the Scheme Administrator and Appeals Officer to take the payment of a subvention as a starting point. However, in this case it would appear that matters related to the contract of care, invoicing of in-patient charges by the NAHB, the payment of these charges and receipts issued were not investigated fully. Evidence which would have been available on these matters (invoices, and HSE receipts) do not appear to have been available to, or sought by, the Appeals Officer. When such evidence was provided subsequently to the Appeals Officer, in the course of this investigation, he took the view that this did not constitute evidence which warranted a revision of his original decision.

It also appears that the Appeals Officer put the burden of proof, and responsibility for the production of evidence, on the appellant, even though information would have been available to him had he requested it from the Health Service Executive.

In his response to the Draft Investigation Report the Appeals Officer stated that he was satisfied that his decision accorded with the evidence made available to him, and that it was correct in law. More detail on the Appeals Officer’s response is set out in the next section.