Health Insurance Claim refused - grounds to appeal

Muns11

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My husband had been on a public waiting list for the last 5 years or so for sinusitis, before we took out our health insurance. Our previous policy had lapsed for a few years as we simply couldn't afford it. Since taking out the policy three or four years ago he has developed new, different symptoms. He decided to go privately as his health was being severely affected. It was discovered that it wasn't his sinuses at all but a tumor in his paranasal cavity, a rare one for a man his age (39).It was a benign (thankfully) Juvenile Nasopharangeal Angiofibroma, that was lying dangerously close to his internal carotid artery.. He had treatments in two different hospital as the first hospital wasn't equipped to deal with him, he needed a specialist.
Now the health insurance are refusing to pay the claim as they're saying it's a pre existing condition.
Have we grounds to appeal as he had new symptoms since the policy was enforced and it is in fact a new condition.

Any advice welcome as I'm in a panic as to how we are going to possibly pay the extortionate bills and there are more to come.
 
Your specialist will need to give you a letter saying that it is a new condition and not related to the old condition.

If he does that and the insurer still rejects the claim, you can go to the Ombudsman.

Brendan
 
Your specialist will need to give you a letter saying that it is a new condition and not related to the old condition.

If he does that and the insurer still rejects the claim, you can go to the Ombudsman.

Brendan
Thank you Brendan, much appreciated.
 
Hi,

It is important to note that things get a little grey as we go into T&C's and legal documents. Most insurers have a statement like this in their T&C document. "Whether a Medical Condition is a Pre-existing condition will be determined by the opinion of Our Medical Director." VHI leaves it at that. Laya and Irish life used to add a line that says "Their decision is final." It may be wise to check what your insurer's document says. It may seem like a small line but it makes a big difference. The Ombusdman is just there to check that the T&C's of the contract and any relevant laws has been complied with. Where this argument will play out is in the medical information supplied, that the Medical Director of the insurer uses to make their decision.

The definition of a pre existing condition is the next important element. Vhi is as follows "Pre-existing Condition means an ailment, illness or condition, where, on the basis of medical advice, the signs or symptoms of that ailment, illness
or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the contract."

The insurer may argue that it was the tumour undetected that caused the symptoms all along and therefore it was present in the 6 months before insurance was taken out, regardless of whether you were aware of that or thought it was some other sinus issue. The medical information your consultant supplies may be able to disprove such an argument.
 
"Whether a Medical Condition is a Pre-existing condition will be determined by the opinion of Our Medical Director." VHI leaves it at that. Laya and Irish life used to add a line that says "Their decision is final."

That is very interesting.

But I doubt it would stand up to the Ombudsman's investigation. An employee/consultant of the company could not unreasonably dismiss a claim.

Brendan
 
Absolutely go to the Ombudsman if you get no satisfaction from your health insurer. You have nothing to lose and it’s free.

A few years ago I took a case to the Ombudsman as the VHI refused to pay for an expensive medical procedure. The VHI were very sympathetic and explained in great detail why they could not pay for the procedure and were adamant it was not covered.

Once the Ombudsman contacted the VHI they did an instant u-turn and offered to pay the claim in full if the complaint was withdrawn.

My guess is some claims, that do not clearly fit into a category box are routinely turned down, even those they know will likely succeed as they also know many will not take the next small step to the Ombudsman.
 
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My guess is some claims are routinely turned down,

That is a wild guess and I am sure it is wrong.

Of course, if you have any evidence for it, you should report it.

If you have even a strong suspicion of it e.g. two similar valid claims being "routinely turned down" you should refer it to the Central Bank(?).

Brendan
 
If you have even a strong suspicion of it e.g. two similar valid claims being "routinely turned down" you should refer it to the Central Bank(?).
Would it not be the HIA?
Q. How do I make a complaint about my private health insurer?
If you wish to make a complaint in relation to your private health insurance, you should first discuss it directly with your insurer. If you are unable to resolve your complaint, you may contact the Financial Services and Pensions Ombudsman. The decision of the Financial Services and Pensions Ombudsman is binding on all parties unless the decision is appealed to the High Court. Alternatively, you may contact the Health Insurance Authority for information.

You also have a right of access to the courts in respect of disputes with insurers.

The Financial Services and Pensions Ombudsman may be contacted at:

The Financial Services and Pensions Ombudsman.
Lincoln House,
Lincoln House,
Dublin 2.

www.fspo.ie
Tel: 01 6620899
e-mail: [email protected]
 
Thanks ClubMan

That is why I put a ? after the Central Bank. I thought that there might be some other body involved.

Brendan
 
That is very interesting.

But I doubt it would stand up to the Ombudsman's investigation. An employee/consultant of the company could not unreasonably dismiss a claim.

Brendan
You are correct, they cannot. Which is why the medical info both sides use to back up their argument, particularly around timing and types of symptoms, along with a thorough examination of the T&C's, is what will win/lose the complaint when examined.

If anyone is interested, if you go on the financial ombudsman website, fspo.ie, you can read their legally binding decision reports on the pre existing condition issue. You can search by health insurance, and rejection of claims as filters.
 
You are correct, they cannot. Which is why the medical info both sides use to back up their argument, particularly around timing and types of symptoms, along with a thorough examination of the T&C's, is what will win/lose the complaint when examined.

If anyone is interested, if you go on the financial ombudsman website, fspo.ie, you can read their legally binding decision reports on the pre existing condition issue. You can search by health insurance, and rejection of claims as filters.
The financial ombudsman turns down 82% of cases within Health insurance.
18% of cases are upheld.

This should explain how strongly they side with the insurer and how well the ombudsman will help.

The decisions are below - and it is very disturbing reading them - especially when a lot of ill patients are now deceased due to the ombudsman siding with the insurance companies and refusing to approve a necessary treatment that ultimately has killed patients.


https://www.fspo.ie/complaint-outcomes/decisions/
 
The financial ombudsman turns down 82% of cases within Health insurance.
18% of cases are upheld.

This should explain how strongly they side with the insurer and how well the ombudsman will help.

The decisions are below - and it is very disturbing reading them - especially when a lot of ill patients are now deceased due to the ombudsman siding with the insurance companies and refusing to approve a necessary treatment that ultimately has killed patients.


https://www.fspo.ie/complaint-outcomes/decisions/
If the ombudsman refuses a complaint - one has 35 days to take the case to the high court - to appeal the ombudsman decision

I assume not everyone can take a case to the high court ......

https://www.fspo.ie/complaint-outcomes/decisions/
 
AFAIK there was a change in regulations a few years ago whereby the issue of pre-existing complaints had been made an objective judgment as distinct froma truthful but subjective one by the policyholder / proposer.

You could have a medical condition presenting with no symptoms but the health insurer's medical adviser could opine that the condition must or probably did exist even though you had no knowledge.
 
The appeal system is not really conducive to a private individual appealing an FSPO decision because of the costs risk.

To appeal a FSPO decision you must proceed by way of motion to the High Court.
You will nominate the FSPO as defendant/respondent.
However, you will have to add in the insurer to the proceedings as a notice party.
If you lose you could face a large bill and few people can afford that.
IMHO this is very unsatisfactory.
 
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