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Challenging Refused Health Insurance Claims


Sometimes, despite the best laid plans, things can go wrong or mistakes can be made;  likewise with private medical health insurance plans.  As we talked about elsewhere on Positive Health Insurance’s blog, there can sometimes be disagreements and misperceptions on whether new symptoms are related to pre-existing conditions.  This can lead to insurance claims being refused on the basis that treatments for current conditions fall under the category of ‘exclusions’ from pay outs.

Such times can be distressing for patients, when their understanding is that their claim is legitimate because conditions are unrelated.  It may also be that they have had this conversation with a doctor or consultant, but then the report sent to the medical insurance brokers or insurance company does not clearly explain that conditions are unrelated.

It is an unfortunate fact of life that medical professionals spend whole careers understanding their specialism, with new research emerging regularly that changes their understanding of the environment in which they work.  It is doubly unfortunate that despite amazing knowledge and understanding of their field, their capacity for clear communication during administrative tasks, such as liaising with private medical insurance companies, can fall short of expectations of the patient.

The Daily Telegraph discussed one such case, which perhaps unsurprisingly to some of our customers concerned misunderstanding over gynaecological conditions.  On this occasion all was rectified due to this newspaper’s consumer watchdog acting on behalf of the woman claimant.   

 The moral of this stressful tale is that sometimes, despite the professionalism of an insurance representative with whom you may have a great rapport, they will be speaking on behalf of under-writers who may not necessarily be as medically literate as we might hope; after all, despite vast experience, they are not medics and must rely upon the information given to them by your consultant or doctor.  This is cold comfort when stuck in the middle and out of pocket, of course.

In such circumstances, of a disputed claim, the good news is that decisions can be over-turned in light of new evidence.  It is also worth realising in advance of such mistakes that if you intend to make a claim for treatment, you should talk to your health insurance broker in advance, as well as your consultant, to check that both are clear about your having medical conditions that could be interpreted as related, but which need to be clearly communicated about to minimise upset and disruption.

This can be difficult for some people to handle and if a person is elderly, or not particularly assertive, things can get tricky if they feel alone in what is essentially a legal dispute.  Fortunately, there are numerous consumer advocacy agents out there now, from radio programmes, to newspapers and specialist charities who will intervene and act as a claimant’s representative.

At Positive Health Insurance our brokers are trained to deal with medical insurance claims sensitively and professionally.  If you think that symptoms you are about to receive medical treatment for are acute and new, but perhaps could be confused with a chronic condition, or ‘pre-existing illness’, be sure to get in touch with us at the earliest opportunity, to avoid any unnecessary confusion and expedite your claim quickly, so you can get on with your life with the minimum of fuss.



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