# Healthcare Insurance provider refusal after 7mo delay disputed preexisting condition.



## LittlePiggy (28 Sep 2010)

I had an operation in March in a private hospital which was supposed to be covered by my Healthcare Insurance provider. 

Within the last two weeks I have received notification from them that they are not paying my claim as it is a pre-existing condition. I dispute this as it was not pre-existing. I don't really want to go into details as its a bit embarrassing.

The hospital in question has since written two letters to me and made one phone call demanding payment. 

I am a bit shocked at their aggressive attitude and was wondering if anyone has had experience of a situation similar to this, and how you managed it.

I am angered that the health care insurance provider is allowed to take 7 months to sit on the claim, and then when they give the thumbs down I am hunted down really aggressively. 

I was told that "in the current climate they need the money quickly" but why is it always us little ones that have to fix this problem? 

A discussion for another day I think!


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## ajapale (28 Sep 2010)

Title expanded to reflect question more fully.


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## Darthvadar (28 Sep 2010)

If you really feel that you're being unfairly treated by the insurance company, I'd suggest a call to the Financial Ombudsman's office.....

[broken link removed]

Can't hurt to check out what your rights are....

Darth...


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## scuby (28 Sep 2010)

i presume the insurance company are going on the details your GP/Consultant provided on the claim form ? 
Also, the hospital may not have sent in the claim straight after your admission so the 7 month delay may not be anything to do with the insurance comp.
Have you contacted your consultant to write a letter giving the medical history ? 
if the condition was there prior to you joining the policy then it's pre-existing, even if you did not know about the condition. the claim is looked at from the info the Dr gives, they cannot just decide it pre-existing.... 
contact your gp/consultant for a letter, and advise the hospital you are appealing it


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## NovaFlare77 (28 Sep 2010)

You don't mention which insurer you're with, but all three of the insurers have a definition of a pre existing conditon in their rules. It's usually defined as a condition that was present before joining, but not necessarily diagnosed. Have a look at your policy documentation to see what the definition in your case is.

In most cases, the determination of pre-existing is made by your consultant in the relevant section of the claim form. You should clarify with your insurer how the determination was made in your case and ask for a copy of the relevant documentation. If it was a case that your consultant stated that it was a pre existing conditon, then you should discuss this with him/her as it may have been a mistake.

If it is a mistake, also ask your insurer how to go about fixing that. It may be a case that they'll request a report from another doctor or consultant or they may ask to see other relevant medical records. 

However, there is the possibility that it is not a mistake and that the consultant believes your condition developed on a date prior to you starting health insurance. If this is the case, then your insurer assessed the claim on that basis, hence the rejection. However, if I were in this position I'd strongly query the consultant as to how he/she made that determination (politely of course). If I'm going to end up with large medical bills, I'd want to be certain of the consultant's certainty in the matter.

If the consultant says it is pre existing and you are certain that it is not, then check with your insurer if there are any other avenues. I don't think there are, but it can't hurt to ask.

With regards to the 7 month delay, that isn't uncommon but it's not an everyday occurence. In most cases that I've seen, the insurer requested more information from one person or another and it took that long to get a reply. However, do quiz your insurer on that as well. If they say they requested additional information, ask them who they contacted and how often.

Also, before you were admitted to hospital, did you confirm your cover with your insurer? You're not obliged to, but if you did and they told you at that stage that it would be covered without mentioning anything about the pre existing waiting period, then it weakens their grounds for rejecting the claim and you should refer back to it.

If you wish to refer the matter to the Financial Ombudsman, you need to complete the insurer's internal complaints procedure first, by asking for a Final Response from your insurer. However, if any of my advice above brings new information to light, engage with your insurer to make sure they've had every opportunity to re-assess the claim before referring the matter to the Ombudsman. If nothing else, it makes your insurer look bad if you can show you gave them new information but they did nothing with it.

Hope that helps!


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## NovaFlare77 (28 Sep 2010)

scuby said:


> i presume the insurance company are going on the details your GP/Consultant provided on the claim form ?
> Also, the hospital may not have sent in the claim straight after your admission so the 7 month delay may not be anything to do with the insurance comp.
> Have you contacted your consultant to write a letter giving the medical history ?
> if the condition was there prior to you joining the policy then it's pre-existing, even if you did not know about the condition. the claim is looked at from the info the Dr gives, they cannot just decide it pre-existing....
> contact your gp/consultant for a letter, and advise the hospital you are appealing it


 
Sigh.... scuby manages to get into six lines what it takes me pages to say! DOH!!


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## Marietta (28 Sep 2010)

NovaFlare77 said:


> Sigh.... scuby manages to get into six lines what it takes me pages to say! DOH!!


 

You do very well NovaFlare, your expertise in the health insurance area is very evident in all of your post.


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## Sue Ellen (28 Sep 2010)

Marietta said:


> You do very well NovaFlare, your expertise in the health insurance area is very evident in all of your post.



Indeed it is very helpful and much appreciated


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## LittlePiggy (29 Sep 2010)

Many thanks for all replies, this is incerdibly helpful. I have indeed contacted the consultant who carried out the op, and he is sure it was not pre-existing so hopefully they will help me out. I am ringing the healthcare provider today to try to understand how they reached this conclusion as well.

_"the claim is looked at from the info the Dr gives, they cannot just decide it pre-existing...."_

Nice to know. Thats what confuses me then, because the consultant made it perfectly clear that this is NOT pre-existing, in his view. I am therefore not sure how they have come to this conclusion.

_"Also, before you were admitted to hospital, did you confirm your cover with your insurer?"_

I checked about cover for the hospital, but neglected to check if the op itself was covered, I was assured it was by the consultant so didn't pursue. Lesson learned there I think, but I still believe I am right.

_"contact your gp/consultant for a letter, and advise the hospital you are appealing it"_

I have done the first bit and am sending a letter to the hospital about the second part... the trouble is that they appear to be, in the nicest way possible, a bunch of bullying thugs and I don't know how much time I have before they send big men around my house.


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## scuby (29 Sep 2010)

the Dr will usually state how long the symptoms were present along with the first date of consultation from when you saw him, if this is prior to the begining of the policy, its pre-existing. 
Just ring the accounts Dept in the hospital, don't waste time on a letter. and tell them you have spoken with the insurance Comp and the consultant and are trying to get the issue resolved. You should also ask your GP for a letter as he would have been the one that referred you to the consultant, and would have a records of the condition, when first detected, treated etc


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