Health Insurance Health Ins claim refused - appealing

I was told again on the 23rd, that it was deemed pre-existing due to the consultants report they got. But my mother wasn't being treated for gallstones at any stage before June. She had suspected ulcers and they were looking at the stomach on and off, but the gallbladder had not been looked at before mid June. The policy was with same insurer, but was deemed an upgrade. She didn't seek it out, she was only asking should she change based on fact her husband had passed away and he had been on her previous policy.

They were able to tell me straight away last week that her old policy didn't cover it. When I asked that back in June they told me I would have to get a call back from them.

I'll give the Ombudsman a go just for the hell of it, but I'm not holding my breath.
 
intothewest said:
I was told again on the 23rd, that it was deemed pre-existing due to the consultants report they got. But my mother wasn't being treated for gallstones at any stage before June. She had suspected ulcers and they were looking at the stomach on and off, but the gallbladder had not been looked at before mid June. The policy was with same insurer, but was deemed an upgrade. She didn't seek it out, she was only asking should she change based on fact her husband had passed away and he had been on her previous policy.

They were able to tell me straight away last week that her old policy didn't cover it. When I asked that back in June they told me I would have to get a call back from them.

I'll give the Ombudsman a go just for the hell of it, but I'm not holding my breath.
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Think the only option is to go to the press.
 
Saavy99 said:
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I think so too, once this story hits the press, Elderly lady, a customer of VHI for 50+ years denied cover.
I reckon they will be ruptions.
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Seems the only way to get anywhere with this.
Getting the story out there is hard though
 
So there is little to report back progress wise. Last week I received the CD with the conversation I had with them in June. This was requested early December, and they said they were sending it out then. They also said they would send me the conversation my mother had with them three days before me in June, but the letter with the CD said they couldn't send me that without my mother's permission. This is the first I heard of that, it wasn't mentioned to me in Dec they would need her permission...plus, I am down as a named contact on her policy. Also, in December, they told me that a webchat I had with them (when I enquired with the operation code) they told me in December that that webchat stated their benefits line was busy, and if I wanted to hold or request a call back. The webchat detail they sent me in the letter with the CV doesn't state that. It says that I would need to call the benefits line to ask that. Yet, when I asked on webchat in December, if her old policy covered that operation code, they were able to answer me with a yes/no answer on the webchat...
 
Absolutely go to the Ombudsman.

It seems to me that a lot of providers (Not just health care) wear down their complainants, who then get fed up or just complacent so complaints are routinely rejected by these providers. The few that do go to the Ombudsman can be settled before any adjudication.

A few years ago the VHi refused to cover an expensive cardiac procedure for one of my family members. They wrote a sympathetic and detailed letter outlining the reasons why the claim was not allowed. This decision was appealed etc and they issued their final response still saying no.

Complaint was made to the Ombudsman who accepted the case and wrote an initial letter to the VHI. That was as far as it went, once the VHI saw the Ombudsman was involved they were able to instantly do a complete u turn and offered to pay for the procedure in full if we withdraw our complaint.

If you think you have a case, go to the Ombudsman.
 
intothewest said:
Someone said to me on the general issue of confirming cover before the procedure, that they would have let the people in the Hermitage take care of that. Is that correct? And if the Hermitage got the ok from the insurance to say that they would be paid, it's now their problem, not ours. But am I right that this doesn't happen? That it's up to the patient to find out all of this in advance?
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Getting the hospital or consultant to confirm that the insurance will cover the treatment is something that my family members do any time health insurance is used.

While the legal responsibility to pay the bill/claim from the insurance lies with the patient, the hospital is obviously in a much better position to clarify matters with the insurer than a layperson.

Not much help to the OP, I know.
 
twofor1 said:
Absolutely go to the Ombudsman.

It seems to me that a lot of providers (Not just health care) wear down their complainants, who then get fed up or just complacent so complaints are routinely rejected by these providers. The few that do go to the Ombudsman can be settled before any adjudication.

A few years ago the VHi refused to cover an expensive cardiac procedure for one of my family members. They wrote a sympathetic and detailed letter outlining the reasons why the claim was not allowed. This decision was appealed etc and they issued their final response still saying no.

Complaint was made to the Ombudsman who accepted the case and wrote an initial letter to the VHI. That was as far as it went, once the VHI saw the Ombudsman was involved they were able to instantly do a complete u turn and offered to pay for the procedure in full if we withdraw our complaint.

If you think you have a case, go to the Ombudsman.
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Do you mind me asking - had it been checked in advance by yourselves, if the procedure was covered? Or on what grounds did they deem it not covered? Was it because it was a pre-existing condition?
 
Our complaint was totally different to yours.

The point I am making, no matter what your complaint is, if you think the VHI’s decision is unfair, do not just accept what they say as it seems some complaints are routinely rejected, even those that they know might be upheld by the Ombudsman. I would guess the VHI do this as they know that many who make complaints will drop the issue once the VHI appeal panel also rejects the claim.

If you think the VHI’s decision is unfair, it costs nothing to take that one extra step to the Ombudsman, you have nothing to lose, and it is free.
 
intothewest said:
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.
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I do not know but if I had an issue I would contact Dermot Goode and just see what steer he would give you [email protected]. I have found him to be superb in terms of his understanding of this opaque form of insurance. I know he charges a fee for doing renewals etc but maybe he can just tell you where to go with your complaint?
 
Sadim said:
I do not know but if I had an issue I would contact Dermot Goode and just see what steer he would give you [email protected]. I have found him to be superb in terms of his understanding of this opaque form of insurance. I know he charges a fee for doing renewals etc but maybe he can just tell you where to go with your complaint?
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I contacted him in the past and enquired about this and the reply is below in bold -


Thank you for your enquiry to Total Health Cover. We are the leading advisors on health cover in Ireland and the only company that deals exclusively on health benefits.
We can review your cover for you across all providers, but we have to charge a fee of €125 to cover our costs as we don’t operate on a commission basis. This ensures our customers get best advice at all times across all health insurers (covering 335 plans). Please note that before we recommend any alternative options, we will complete a full fact-find with you to understand your exact requirements in relation to the ideal health cover for you. This ensures that any suggested alternatives match your key requirements in terms of both price, benefits, and healthcare provider.
Just to note, we don’t advise on how to access treatments or processes, as this is something that would have to be discussed with the Insurance company directly.
 
twofor1 said:
Our complaint was totally different to yours.

The point I am making, no matter what your complaint is, if you think the VHI’s decision is unfair, do not just accept what they say as it seems some complaints are routinely rejected, even those that they know might be upheld by the Ombudsman. I would guess the VHI do this as they know that many who make complaints will drop the issue once the VHI appeal panel also rejects the claim.

If you think the VHI’s decision is unfair, it costs nothing to take that one extra step to the Ombudsman, you have nothing to lose, and it is free.
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How long did this process drag on for, and why do you think they caved?
sounds like it was all very necessary
 
Maybe 3 months.

The Ombudsman accepted the case and wrote an initial letter to the VHI asking a few specific questions.

The only reason I can think of for the immediate and complete uturn is the VHI knew that if this complaint went to adjudication, it would be upheld.

Intothewest, the Ombudsman has a good search facility that will throw up decisions on complaints against health care providers relating to pre existing conditions.

https://www.fspo.ie/decisions/

Here’s two that were upheld;

https://www.fspo.ie/decisions/documents/2018-0100.pdf

https://www.fspo.ie/decisions/documents/2018-0070.pdf

There are several more there that were either upheld, partially upheld or rejected.
 
Thanks so much for information on these. I've a look at some of those rejected due to pre-existing. All are for various ailments and reasons, but what I have read so far, are new policies taken out. Some quite recently before an ailment was found...and some with long waiting periods of 5 and 10 years for pre-existing conditions cos they are new policies (and due to their age). Also seems to be a very grey area about what is deemed as pre-existing, because the insurer will use their own medical advisors to determine if it's pre-existing or not. And you could go into a procedure believing it isn't pre-existing based on info from your GP and/or Consultant, but that could still be disputed by an insurer - but they won't (and cannot) determine this until after a procedure, at which point it is too late.
 
Very interesting - like intothewest has said - the cases that were approved were very dependent on the case officer it seems other than anything else.

Just wondering if there has been any progression or update?
 
No update on it no. I'd requested our recordings early Dec. They said they were sending them out. Second week in Jan I got just mine, and the accompanying letter said that I needed to get her permission for them to send me her recordings. That hadn't been mentioned in Dec. I am listed as a point of contact on her policy. I told them of these, they said they would check, and week before last they came back to me to say that she would need to contact them to confirm the recording of her conversations could be sent to me.

So when I get that I will compile all for the Ombudsman. If anyone has any guidelines for that, will be very much appreciated.
 
intothewest said:
No update on it no. I'd requested our recordings early Dec. They said they were sending them out. Second week in Jan I got just mine, and the accompanying letter said that I needed to get her permission for them to send me her recordings. That hadn't been mentioned in Dec. I am listed as a point of contact on her policy. I told them of these, they said they would check, and week before last they came back to me to say that she would need to contact them to confirm the recording of her conversations could be sent to me.

So when I get that I will compile all for the Ombudsman. If anyone has any guidelines for that, will be very much appreciated.
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It would be helpful if someone gave advice for preparing the case for sure.
 
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