Irish Life Health Can Aviva ask for money back?

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phanteon

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Hi, I joined Aviva health in December 2009, I was 49 years old. It was my first time to take out Health insurance.
In February 2012 I had a heart valve operation and Aviva settled the claim in July which came to about 36,000 Euro.
In December 2012 I received a letter from Aviva asking for five years medical records, in order that they could process an outstanding claim from a doctor in the hospital where I had my operation.
These records show that i had a pre existing heart problem when I joined Aviva.
Before I had my operation I rang Aviva and gave them the codes for the procedures I was about to have. They said I was covered by Aviva and wished me well.
What should I do now ?.
Can Aviva demand the money back that they paid out?
 
So are you saying that you failed to disclose an existing medical condition when you took out the health insurance or what???
 
I told the truth at the time of joining.
I did not know I would have to have the operation so soon
 
I have been told by Aviva that they record all their phone calls.
I recently joined and questioned some of their expiry dates of some of
their contracts with various hospitals. When I asked for confirmation in writing
they said all their calls were recorded. Browtal
 
phanteon said:
I told the truth at the time of joining.
I did not know I would have to have the operation so soon
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Well if you told them about the pre existing condition at the time and they accepted you without any conditions, then I don't see what you are worried about... Since they have already started to pay out on it, one can only assume that they have already accepted liability for the costs and showing them a document that confirms what they already know, will not change that.
 
I think you should be alright if they pre-approved the treatment but it does look like a grey area with pre-existing conditions and when they investigate/decline cover. From their FAQ, a condition can be pre-existing even if you don't know about it - so even being fully truthful when you apply doesn't help: "Please note that a pre-existing condition is determined from the date the condition commences rather than the date upon which the member becomes aware of the condition. A pre-existing condition may therefore be present before giving rise to any symptoms or being diagnosed by a doctor". How is a member supposed to deal with that? You go to hospital and tell them you have health insurance, you get treated (not all treatments are pre-approved - often the forms are submitted after the treatment) - and can Aviva then say sorry, you might not have known about that condition but it was pre-existing when you took out the policy...
 
orka said:
I think you should be alright if they pre-approved the treatment but it does look like a grey area with pre-existing conditions and when they investigate/decline cover. From their FAQ, a condition can be pre-existing even if you don't know about it - so even being fully truthful when you apply doesn't help: "Please note that a pre-existing condition is determined from the date the condition commences rather than the date upon which the member becomes aware of the condition. A pre-existing condition may therefore be present before giving rise to any symptoms or being diagnosed by a doctor". How is a member supposed to deal with that? You go to hospital and tell them you have health insurance, you get treated (not all treatments are pre-approved - often the forms are submitted after the treatment) - and can Aviva then say sorry, you might not have known about that condition but it was pre-existing when you took out the policy...
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This is the main thing putting me off buying private health insurance - given my age (43) - could most ailments not be somewhere in the background at this stage? I'd pay for a few years and then have to have treatment which then turns out to have to be paid by me anyway, allied to the fact that you have to have a more expensive bed than you actually want (i couldn't give a fiddlers about a private or semi-private bed, all I would really want from health insurance is quicker access to better consultants than other people get in this great democratice republic of ours).
 
You had a pre-existing condition and Aviva shouldn't have paid out. Are you absolutely positive they said they would cover your operation prior to having it done not just something like saying your plan covers the procedure. To be honest I would be worried. The fact that they have paid out so far is a very good sign but someone made an error at Aviva. Dereko1969 is right. At age 43 many ailments are already there and most things would not be claim able until the end of the 5 year waiting period eg most orthopaedic and cardiac conditions
 
orka said:
I think you should be alright if they pre-approved the treatment but it does look like a grey area with pre-existing conditions and when they investigate/decline cover. From their FAQ, a condition can be pre-existing even if you don't know about it - so even being fully truthful when you apply doesn't help: "Please note that a pre-existing condition is determined from the date the condition commences rather than the date upon which the member becomes aware of the condition. A pre-existing condition may therefore be present before giving rise to any symptoms or being diagnosed by a doctor". How is a member supposed to deal with that? You go to hospital and tell them you have health insurance, you get treated (not all treatments are pre-approved - often the forms are submitted after the treatment) - and can Aviva then say sorry, you might not have known about that condition but it was pre-existing when you took out the policy...
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I doubt that such a clause would stand up in court since it goes to the very heart of insurance so to speak. And I doubt that Aviva would even let it go that far since they probably have been using it to avoid paying out in the past and could ill afford to have it go against them.
 
OMD said:
You had a pre-existing condition and Aviva shouldn't have paid out. Are you absolutely positive they said they would cover your operation prior to having it done not just something like saying your plan covers the procedure. To be honest I would be worried. The fact that they have paid out so far is a very good sign but someone made an error at Aviva. Dereko1969 is right. At age 43 many ailments are already there and most things would not be claim able until the end of the 5 year waiting period eg most orthopaedic and cardiac conditions
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I rang them and told them I had to have two procedures. They told me I was covered after leaving me on hold so that they could check my eligibility and wished me all the best for my upcoming operations.
 
Youre not covered for treatment of pre existing illness for first 5 years after joining. Did you know this?
Im surprised that they didnt clarify this with you when you rang them re your procedures.
 
Emiso said:
Youre not covered for treatment of pre existing illness for first 5 years after joining. Did you know this?
Im surprised that they didnt clarify this with you when you rang them re your procedures.
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Yes I was aware of the 5 year rule and expressed my concern to the surgeon who was going to perform the operation.
He said ring Aviva and give them the codes.
I did this, The person in Aviva who I was speaking to said she would check to see if I was covered. She came back to me a few minutes later and said I was covered. Then she put me on hold so that she could double check my eligibility and again came back and said " Yes you are covered".
I was surprised but happy.
As one of the posters said " the calls are recorded". I hope they are.
So of course I went ahead and had the operation and thank God everything went well.
 
Emiso said:
Youre not covered for treatment of pre existing illness for first 5 years after joining. Did you know this?
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Just note that this is not always the case. I am with Avivas too via my employer and the 5 year rule for existing conditions is waived. So much so, that if I discover that one of my children needed grommets, I could ring them and he/she will be covered there and then. I found this out when I enquired about adding my daughter on the policy again for a congenital condition and I may want to have surgery on this 5 years from now. The customer representative then apologised as he saw that the waiting period was waived with my employer and my daughter could have the surgery immediately.
 
insurance companies will tell you over the phone that the procedure's/Hospital/Dr are covered, but cannot say anything about having you procedure itself covered until a claim is submitted with the details from the surgeon.
The surgeon would have to provide details of the diagnosis, date you first consulted the consultant, date referred from the GP, first time you saw the GP for the complaint. All this would be looked at when determining when the condition arose etc. Best thing is to ask GP/Consultant to send in a letter querying the non payment, and if in relation to the pre-existing, then get them to send in details of you medicla history if in fact it's not pre-existing ?
 
scuby said:
insurance companies will tell you over the phone that the procedure's/Hospital/Dr are covered, but cannot say anything about having you procedure itself covered until a claim is submitted with the details from the surgeon.
The surgeon would have to provide details of the diagnosis, date you first consulted the consultant, date referred from the GP, first time you saw the GP for the complaint. All this would be looked at when determining when the condition arose etc. Best thing is to ask GP/Consultant to send in a letter querying the non payment, and if in relation to the pre-existing, then get them to send in details of you medical history if in fact it's not pre-existing ?
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Aviva Have paid out the 36,000.

A doctor sent in his claim late and Aviva are looking for five years medical records in order to process this claim.
This claim related to some test ( I don't know which) I had on the morning I was leaving the hospital after my operation.
If I have to pay for this test out of my own pocket, then so be it. But if Aviva ask for the 36,000 back then that is a different story.
I was wondering did anyone hear of this situation before.
 
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