Health Insurance Claim(haemochromotosis)

blackrovers

Hey i'm just wondering what my rights are or what i'm entitled to do. I've found out awhile ago that i have haemochromatosis and that the solution for this is the withdrawal of blood(basically giving a pint of blood until my iron level reaches a good level).

Now my problem is that i have been getting this procedure done with my gp and i rang my health insurance to see if this policy is covered. I was told it is and that i can go ahead. I was with the health insurance for 6 months at this stage and that i've covered the waiting period for any new illness etc. Now the insurance crowd are ringing me almost 9months after questioning whether i'm covered.

They say that this condition is herditry and that because of this i'm not covered. Now the reason they are saying this is that they claim my doctor said this. Now there is no one in the family that has it so i don't know what the situation is.

Now to the problem i went ahead getting this taken care of by going to my gp, if i didn't it would make no real difference to my health in the near future, so i went ahead on the bases that i was covered.

Do i have a leg to stand on or am i gonna have to pay for all the visits to the gp etc?!
Any help please

dudara

Moved to Banking & Insurance & Pensions

dudara

NuMarvel

I'm presuming that the doctor has submitted a claim form to your insurer and it's here that it's stated that the condition was hereditary.

Firstly, talk to your insurer and tell them that you believe the doctor was incorrect when he/she stated this and ask them what the process is to get this amended. Also ask for a copy of the claim form that the doctor sent in so that you can see for yourself. You should have no problems getting this, but if your insurer objects for some reason, you are entitled to a copy of the form under the Data Protection Act.

Also get onto your doctor and tell him/her what you've been told by your insurer. Ask the doctor to clarify what was put on the claim form. If they stated the condition is hereditary, ask them how they came to that conclusion. Make sure you're happy with the answer you're given.

The call you initially made to your insurer may also be of use, but I'd say that the advice given to you at that time was based on what you believed to be correct so it may not be possible to hold them to this call. On the other hand if they told you that you are covered, without them asking any questions of you about onset dates, where you're getting treated etc, then it's probably a different story. If you want to go down this route, you can get a copy of the call notes and the call recording, if one was made. See how you get on with the doctor and the claim form first though.

I've worked for a health insurer in the past and it has occured in the past that the doctor has put the wrong information on a claim form, leading to situations like this, so you're not the only one that's encountered this. It's not ideal, but it's usually sorted with relative ease depending on the nature of the treatment and hopefully that will be the case for you as well.

blackrovers

thanks NuMarvel for this information. hopefully it will be a matter that gets sorted with ease and without difficulty. thanks again for the info.

DrIndy

The doctor may have inadvertantly filled it out incorrectly. I personally hate filling out forms because they are designed for actuaries and solicitors - not for doctors.

Haemachromatosis IS hereditary - but is autosomal recessive meaning your parents can carry the gene but not have the condition. In addition - it is variably expressed - meaning the environment and your own particular other sets of genes determine when you start collecting the iron to dangerous levels which can be at 18 or 60 (or never).

Thus its not like automatically inherited. And thus you do not have to automatically have to be treated. I think that the insurers are being very fly finding loopholes to stop paying out.

On an aside - the IBTS have started a pilot project where they do the blood collecting for haemachromatosis patients and then use the perfectly normal and good blood as a blood donation. Check with them to see if you can do this locally. When your GP takes off the blood, it needs to go in the waste disposal because it is not collected under the stringent conditions that the IBTS need to be able to use it in the donor pool. This may be an option.

amen

condition was hereditary.

I must be missing something but what has this go to do with anything?

Insured was pass his 6 months waiting period and is covered.

If hereditary conditions are not covered what about if either of your parents had a heart attack/stroke/breast cancer/goes blind etc.
A lot of these conditions are hereditary?

broker2008

The hereditary bit could be related to a pre existing condition. If you only had cover for 6 months, one is not covered for pre existing conditions for 5 years. (Unless you were a member of Caoga ! - http://www.caoga-defenceforces.com/docs/newsflash_april_09.pdf

For us other poor minions:

I have never had private health insurance cover before. What waiting periods will apply?

Age on Joining Accident or injury New Conditions Pre-existing conditions Maternity Out patient benefits

<55 years Immediately 26 weeks 5 years 1 year Immediately

55-59 years Immediately 52 weeks 7 years 1 year 1 year

60–64 years Immediately 52 weeks 10 years 1 year 1 year


65+ years Immediately 104 weeks 10 years 1 year 2 year