7. The Law - NHS charges
7.4 NHS charges tariff
The amount of NHS charges will depend on when the incident or injury occurred. The charges will relate to either treatment provided with admission to hospital or treatment provided without admission to hospital, but not both. This is because out-patient treatment is superseded by in-patient treatment.
'With admission' charges are calculated according to the number of days the injured person stayed in hospital. This is subject to a minimum of one day when the casualty is released on the day of admission. This is known as a ‘day case’ and therefore in-patient treatment does not necessarily involve an overnight stay. Where the casualty is admitted to hospital for more than one day the date of discharge is not included in the calculation.
Under the 2003 Act ambulance charges for the purposes of transporting the patient to hospital are recoverable per person, per journey, regardless of numbers carried by an individual ambulance. This applies to each ambulance journey to hospital, or transfer between hospitals, in relation to treatment of the injuries for which compensation is paid. The ambulance charge will only apply to NHS ambulance journeys and does not include charity funded air ambulances.
There is a limit to the amount of NHS charges that can be recovered. This is known as the "capped" tariff amount. The tariff for treatment and ambulance costs is reviewed each financial year.
NHS treatment and ambulance journey charges
The following table can be used as a quick reference guide to the tariffs:
| Incident date (on or after) |
Out-patient | In-patient | Cap | Ambulance charges |
|---|---|---|---|---|
| Pre 2.7.1997 | £295 | £435 | £3,000 | |
| 02.07.1997 | £354 | £435 | £10,000 | |
| 01.01.2003 | £440 | £541 | £30,000 | |
| 01.04.2003 | £452 | £556 | £33,000 | |
| 01.04.2004 | £473 | £582 | £34,800 | |
| 01.04.2005 | £ 483 | £ 593 | £ 35,500 | |
| 01.04.2006 | £ 505 | £ 620 | £ 37,100 | |
| 29.01.2007 | £ 505 | £ 620 | £ 37,100 | £ 159 |
| 01.04.2008 | £ 547 | £ 672 | £ 40,179 | £ 165 |
| 01.04.2009* | £566 | £695 | £41,545 | £171 |
| 01.04.2010 | £585 | £719 | £42,999 | £177 |
| 01.04.2011 | £600 | £737 | £44,056 | £181 |
| 01.04.2012 | £615 | £755 | £45,153 | £185 |
*For Scottish cases, the effective date for increased charges is 12 June 2009
An example of NHS charges
A patient had an accident on 10 September 2009 and was:
- taken by ambulance to Accident and Emergency to hospital A where they were treated as an outpatient
- transferred and admitted to hospital B for seven days
- transferred again to a specialist unit in hospital C for ten days
All three ambulance charges would be recoverable – a total of £513. In-patient treatment at hospital B and C (a total of 17 days amounting to £11,815) would also be recoverable. The Certificate of NHS Charges would be for £12,328. Out-patient treatment at hospital A is disregarded as it is superseded by the in-patient treatment.
Had the injury led to 100 days treatment at hospital C, the NHS Certificate would show a total charge of £74,878 capped at £41,545. The ambulance charge is incorporated in the recovery, subject to the NHS capped tariff amount.
7.5 The relevant NHS recovery period
The period in respect of which NHS Charges may be recovered by DWP begins on the first day that treatment was provided following the incident.
The period ends on:
- the day a compensation payment is made in final discharge of a claim:
- the date an agreement is made under which an earlier compensation payment is treated as having made in final discharge of any claim; or
- when the appropriate tariff limit is reached.
7.6 NHS exempt payments
Please refer to Schedule 10 of Part 3 of the 2003 Act for listed exemptions of repayment of NHS charges.
If you consider your client is exempt from repayment of NHS charges, please let CRU know, providing all relevant information. You need to do this on a case by case basis.
A compensator who is exempt from repayment of NHS charges will not be issued with a Certificate of NHS Charges, unless CRU have been notified of the exemption after an NHS Certificate has been issued. In these circumstances, CRU will revoke the Certificate of NHS Charges and issue a fresh copy. You must therefore inform the CRU if you receive a Certificate of NHS Charges on a case that you consider to be exempt.
7.7 The Certificate of NHS Charges
Separate legislation covers the recovery of NHS charges scheme and the recovery of benefits.
Therefore the Certificate of NHS Charges is issued separately to the benefits Certificate. The benefits Certificate does not cover both schemes.
CRU will issue the Certificate of NHS Charges as soon as is reasonably practicable. There is no time limit in the legislation in which CRU must issue the Certificate of NHS Charges. The compensator does not have to be in possession of the NHS Certificate at the time they make a compensation payment as NHS charges cannot be offset against the compensation payment. Therefore the amount of NHS charges should not be relevant to the negotiation process. However, if the compensator has not already applied, they must do so within 14 days of making the compensation payment.
If at the time of making a final compensation payment you have not received a Certificate of NHS Charges that you have requested, please contact CRU. This is particularly important if you notified CRU of hospital attendance and therefore expect NHS charges to have been incurred. We will tell you if the NHS Certificate has been issued or if enquiries are still ongoing. This will help avoid getting a demand for payment after your files have been closed.
CRU will issue a Certificate of NHS Charges for all cases except disease claims that occurred after 29 January 2007. Therefore if you have not received your NHS Certificate you should not assume that there are no charges payable.
The Certificate of NHS Charges will include:
- details of the injured person’s identity,
- the date of personal injury which gave rise to the compensation claim;
- the name and responsible body (NHS Trust or Health Board) at which the treatment took place;
- details of the amount of treatment provided, with or without admission;
- the name of the responsible ambulance trust who provided the service;
- the validity period of the Certificate of NHS Charges;
- the total NHS charges due to be repaid up to the maximum recoverable amount.
If there is more than one compensator involved in the compensation claim, provisions under the 2003 Act allow apportionment of NHS charges between compensators. Please advise CRU as soon as possible if you are:
- apportioning liability with one or more compensator(s), and
- not working together with one compensator co-ordinating.
CRU will then advise you of the evidence of the agreement over liability that they need to see so that a revised Certificate of NHS Charges can be issued.
A Certificate of NHS Charges will usually be valid for the life of the claim. If the compensator advises that no NHS treatment was provided CRU will issue a nil NHS Certificate. However CRU carry out compliance checks and where treatment is identified as a result. We can reissue the Certificate of NHS Charges at any time superseding the previous NHS Certificate. This includes cases that have already been settled.
Please tell CRU as soon as possible when you know the outcome of the compensation claim even if you did not make a compensation payment or you are in possession of a ‘nil’ certificate. This will to allow us to close our records. Please use form CRU102, which accompanies the CRU Certificate for this.
If you have any queries on the information contained in the NHS Certificate, please contact the NHS section.
Repayment of the NHS charges quoted on the Certificate should not be sent to CRU if a compensation payment has not yet been made to the injured person. If you send CRU a repayment we will need to make enquiries with the compensator and refund payments where compensation has not yet been paid. The compensator would then be required to resubmit payment at the appropriate time.
7.8 Changes to the Certificate of NHS Charges
Usually the amount contained in the Certificate of NHS Charges cannot be increased where CRU have been supplied with the information in accordance with Section 160 of The Health and Social Care (Community Health and Standards) Act 2003/Section 5 of The Personal Injuries (NHS Charges) (General) and Road Traffic (NHS Charges) (Amendment) Regulations 2006
If a compensator has provided CRU with incorrect or insufficient information, CRU are legally entitled to increase the NHS Certificate. Section 156 (6) of The 2003 Act refers.
Therefore CRU can increase the NHS Certificate if they are provided with incorrect details regarding the:
- injured person,
- injury,
- date of incident,
- hospital details, or
- any other material fact.
There are no time limits for compensator error reviews. We can conduct an error review after the compensator has settled the claim.
7.9 NHS reviews
For incidents after 29 January 2007, Section 156 of the 2003 Act and The Personal Injuries (NHS Charges) (Reviews and Appeals) and Road Traffic (NHS Charges) (Reviews and Appeals) (Amendment) Regulations 2006 require that a review request from the compensator must be submitted:
- while the claim is live or
- within three months:
- of the date on the NHS Certificate if that was after the final compensation payment was made to the claimant, or
- from the date that the compensation payment was made to the injured person.
The request must:
- be in writing
- clearly state the grounds on which a review is being sought.
A review may be conducted for the following reasons:
- a mistake (whether in computation or otherwise) occurred in the preparation of the Certificate of NHS Charges;
- the amount specified in the Certificate is in excess of the amount due;
- it appears that a ground for appeal is satisfied.
When a request to review the Certificate of NHS Charges is received CRU will look at the:
- NHS charges recorded, and
- information provided by the NHS Trust,Ambulance Trust or Health Board.
Any errors, omissions or other changes which may affect the outcome of the review will be taken into account, even if unrelated to your reasons for requesting the review.
If there is no apparent reason to change the NHS Certificate, CRU will contact the appropriate NHS Trust or Health Board. CRU will ask them to check all records to confirm that the treatment details provided are correct and relate to the incident for which compensation is being claimed.
Once the review is complete CRU will either:
- confirm in writing that the Certificate of NHS Charges is correct, or
- revoke the Certificate of NHS Charges and issue a revised version.
CRU can only increase the total amount of NHS charges where the variation is required as a result of incorrect or insufficient information supplied by the compensator. Where this occurs the compensator will be liable to pay the difference to DWP. No time limits apply to compensator error reviews – please see section 7.8 for more information.
7.10 NHS appeals
Under Section 157 of the 2003 Act and The Personal Injuries (NHS Charges) (Reviews and Appeals) and Road Traffic (NHS Charges) (Reviews and Appeals) (Amendment) Regulations 2006, a compensator has the right of appeal against the Certificate of NHS Charges if they think that the Certificate, including a reviewed Certificate, is incorrect. Legislation allows CRU to treat an appeal as a review.
The NHS appeal form is available on this website and should be used to lodge your appeal. If you prefer, CRU can send the form to you by e-mail as a Word document.
An appeal against a Certificate of NHS Charges may be made on the grounds that:
- an amount specified in the Certificate of NHS Charges is incorrect;
- an amount specified takes into account treatment which is not NHS treatment received by the injured person, in respect of their injury, at an NHS hospital;
- the ambulance which transported and or treated the injured person, is not an NHS ambulance service, or;
- the payment on the basis of which the Certificate of NHS Charges was issued is not a compensation payment.
For personal injuries occurring on or after 29 January 2007, the time limit for making an appeal application is no later than three months from:
- the Certificate of NHS charges (including review decisions) was issued, or
- that the final compensation payment was made to the claimant.
An appeal can only be accepted after final settlement of the compensation claim, and full repayment of NHS charges to CRU.
Where payment of the amount specified in the NHS Certificate would cause exceptional financial hardship, the requirement to repay prior to appeal may be waived.
An application for a waiver must be sent to CRU with particulars of the exceptional financial hardship that would be caused by payment of the amount specified in the NHS Certificate. This application should be sent to CRU, not later than three months after the date on which the compensation payment was made.
Please note: The waiver provision applies to the waiving of pre-payment being made prior to an appeal application. This does not mean that payment of NHS charges can be waived where an appeal upholds the Certificate of NHS Charges.
Late appeals may be accepted but only where there are special circumstances for the delay. No appeal may be accepted if it is made one year or more after the date that the right to appeal arose.
Appeals involving English and Welsh NHS Trusts will be heard by an independent tribunal administered by the Tribunals Service. Appeals involving Scottish Health Boards will be heard by the Road Traffic (NHS Charges) Appeal Tribunal for Scotland.
The tribunal may decide that the amount on a Certificate of NHS Charges is correct or it may increase or decrease the amount of charges to be paid.
Following the decision of the tribunal, CRU will either:
- confirm the Certificate of NHS Charges,
- issue a revised Certificate, or
- revoke the Certificate.
Where the amount on a Certificate of NHS Charges is increased following an appeal the compensator will be liable to pay the balance of NHS charges to DWP.
Where the amount on the NHS Certificate is reduced, the balance will be recovered from the NHS Trust, Ambulance Trust or Health Board and will be refunded to the compensator.
An appeal to the High Court (England and Wales) or the Court of Session (Scotland), against the decision of an appeal tribunal, may be made on the grounds that the decision was erroneous in law. This appeal can be made by the:
- compensator,
- Secretary of State, or
- Scottish Ministers.
The appeal tribunal will send you details of how to appeal and the time limits after your appeal has been heard.
In accordance with Section 159 of the 2003 Act, a further appeal may be made against any decision of an appeal tribunal, on the grounds that the decision was erroneous in point of law.
