Laya refusing to pay claim

nqtfarmer

Hello all,
After a brief stint in hospital last August, Laya have decided to not pay the claim as they feel it was for a 'pre-existing condition'. I have already appealed it and after receiving news of the appeal today, I will go to the Ombudsman next. How long do people generally wait to hear back from the Ombudsman re - a decision?

Henry Ford III

I've used the Ombudsman's Office before and it was a long drawn out process. Took a few months. We got a good result eventually though.

nqtfarmer

Thanks for the reply, great to see you got a good result. Obviously the claim won't rise so I think we will take our chances with the Ombudsman

Henry Ford III

https://www.ombudsman.ie/making-a-complaint/what-we-can-investigate/

They can't adjudicate on "clinical judgements" it seems. Might affect you O.P?

nqtfarmer

While researching I saw that, however on the returned appeals letter from Laya they state that it can be forwarded to the Ombudsman. Wait and see I guess

dennyk

nqtfarmer wrote: »

While researching I saw that, however on the returned appeals letter from Laya they state that it can be forwarded to the Ombudsman. Wait and see I guess

Probably standard boilerplate wording they include when denying any claim, to ensure you are aware of your rights. Doesn't mean the Ombudsman will actually be able to examine your specific claim, as every claim will have different circumstances.

vikings2012

Was it an elective procedure which required hospital stay ? Oftentimes, your doctor/surgeon will write to your insurer to obtain pre approval and explain that the condition is not pre existing or provide details to the insurance company of the implications which this ‘pre-existing’ condition is having on your current health.

No harm having a chat with your consultant or doctor who referred you to hospital.

alig1234

This is standard declinature stance for health insurers. Agree if you get a letter from your GP/Consultant saying its not for a pre existing condition they may well review their decision. Your insurer probably has a report from your dr saying you attended for eg a sore throat and ended up having a tonsillectomy so it links the two and moves to declinature. See what your policy states about conditions for pre existing conditions which usually apply for up to five years after the date you select your health insurer.

nqtfarmer

It was elective in that I felt awful and went to the consultant who recommended a scope and tests (hence overnight stays) I’m after forwarding everything to the ombudsman but yes a chat with my GP may be no harm. As stated above bloating from the previous 18 months GP visit has been linked to IBS symptoms. Very unfair

Shazamm

nqtfarmer wrote: »

It was elective in that I felt awful and went to the consultant who recommended a scope and tests (hence overnight stays) I’m after forwarding everything to the ombudsman but yes a chat with my GP may be no harm. As stated above bloating from the previous 18 months GP visit has been linked to IBS symptoms. Very unfair

Any update?

nqtfarmer

Shazamm wrote: »

Any update?

Getting a call from the ombudsman Friday. At least they are willing to listen to both sides

alig1234

if the ombudsman is ringing you to discuss it most likely means insurer has refused to pay claim despite ombudsman involvement and the ombudsman will offer to mediate so insurer will pay something but not all. if you dont agree with this mediation the ombudsmasn will proceed to adjudicate on the issue. if the ombudsman had a letter from your gp saying the two issues are not related this wold help your case.