Thank you Brendan, much appreciated.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
"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."
My guess is some claims are routinely turned down,
Would it not be the HIA?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(?).
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: info@fspo.ie
I have edited my guess.That is a wild guess ......
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.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
The financial ombudsman turns down 82% of cases within Health insurance.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.
If the ombudsman refuses a complaint - one has 35 days to take the case to the high court - to appeal the ombudsman decisionThe 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/
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