Health Insurance Health Ins claim refused - appealing

intothewest

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Hi All.,

My mother is almost 77, and at the beginning of the year my Dad died. Her and Dad had a policy for the last 55 years with same health insurer.

Dad had different treatments over the last 15/16 years, but my mother has only had two hospital related claims. One was in 2019 for a day patient operation in the Hermitage.

She had to change policy this year cos Dad passed away, and it was due for renewal at the end of June. She asked me to help navigate the quagmire that is health insurance, but I wasn't able to make any inroads, despite looking at comparison websites etc. In the end, my mother called them and asked them to advise her on what option to take. We think this was around May time. My understanding from a conversation with them around this time, was that she wasn't covered for two years in some hospitals for pre-existing conditions. At that time (May) she had no pre-existing conditions. She had stomach problems on and off for years, but her GP had been treating them as ulcers. In June, her GP decided to send her for a scan for something and it showed up something which required a keyhole operation.

She rang health insurer on June 22nd about the operation being covered, and they asked her to get a hospital code. She got that and asked me to check with them. I contacted them on webchat on June 25th with the code and they said they would have to call me back about it (I am waiting for them to forward me that webchat as I don't recall the details of it). They said they called me on the 26th, but I don't recall a missed call from them.

The 'new' policy kicked off on Jul 1st. Both my mother and I feel though that we did get confirmation from them that it was ok for her to proceed with the op in the Hermitage. She did, but at start of month, got a letter from ins co saying they had rejected her claim, on the basis that her policy didn't cover her for two years for a pre-existing condition.

There was no break in cover at any stage. Customer of 55 years, She's now super worried, has been back to her GP (who is writing a letter) and has been through enough this year to be frank. Also, her new policy, that they recommended to her was a better policy from her previous one, not a downgrade with less cover.

Any recommendations of how to approach this? It's currently with their Complaints Dept.
 
was there an upgrade in cover? If so, pre existing conditions are not covered for a period. Some insurers do not cover all procedures in all private hospitals. Can you let us know the insurer and the plan type?
 
Her condition was discovered 8 days before the new policy kicked in (Jul 1). It's VHI and her old policy was One Plan 150. Her new policy is PMI 37 13 which was discussed on 17.05.20 as she wanted to get it decided on in time. At that point, her condition hadn't been discovered. It wasn't discovered until June 22nd. My understanding is that it is an upgrade, but it was purely taken on the basis of their advice to her.
 
A customer of 55 years, how sad
That's part of the complete and utter annoyance about this whole thing. And why would an insurance company recommend a policy that entails a two year waiting period for a 76 year old? I know we are all living longer, but she just wanted something that replicated the prev policy and that's what was recommended to her.
 
Does the One Plan 150 cover the Heritage?
I have to find out if the old 150 plan would have covered this years procedure in the Hermitage. It did cover a carpal tunnel surgery there in 2019. Which is partly why she went there again, she knew the lay of the land, how to drive herself to appt's, no city driving etc.
 
If the procedure (gallbladder) was covered under the old policy, but she had the op at start of Sep (new policy kicked in Jul 1), what would that mean does anyone know. I might have to ask them if old policy covered it cos I can't be sure from the policy documents.
 
That's part of the complete and utter annoyance about this whole thing. And why would an insurance company recommend a policy that entails a two year waiting period for a 76 year old? I know we are all living longer, but she just wanted something that replicated the prev policy and that's what was recommended to her.
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You could try making a complaints

 
If the procedure (gallbladder) was covered under the old policy, but she had the op at start of Sep (new policy kicked in Jul 1), what would that mean does anyone know. I might have to ask them if old policy covered it cos I can't be sure from the policy documents.

This a a difficult situation for you and more importantly your mother. You find yourselves in a tricky predicament here.

Given that your mother's diagnosis was on the 22nd of June and that her new policy started on the 1st July it would seem that her condition would be categorised as pre-existing under the new policy.

As you have pointed out she would have to serve two years on the new plan before she could avail of the upgraded benefits of this policy.

However, your mother would continue to be covered for the two years under the terms of her previous plan - One Plan 150.

The question for you is to ascertain whether the procedure and the hospital accommodation availed of were covered by One Plan150.

I hope this is helpful to you and I wish you and your mother well with your appeal.
 
Ask for a copy of the recorded conversation with her under GDPR, she should have been made aware of an increase in waiting/non-covered periods.
 
Thats awful 55 years of loyalty and the rest of us are charged extra on our insurance to go someway to keep elderly people covered and ensure they get the treatment they need.
 
Ask for a copy of the recorded conversation with her under GDPR, she should have been made aware of an increase in waiting/non-covered periods.
They are sending them out on a CD to me. Though it's not all the conversations, not the ones from May when the new policy was discussed.
 
It's very important for future references to email those chats to youself. You are given an option to do so.
 
Good to know, wasn't aware of that.
That goes for anything you do via chat with customer care. Not healthcare but I got a lot of money back after an agent confirmed something but the company denied it did. Obviously that agent doesn't work for them and is suing them, and I swore an affidavit in the agents defence.
 
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