Health Ins Claim Refused

intothewest · 07-02-2021 12:13am

Nothing yet no. Last week they confirmed that my mother will have to contact them to give her permission for them to send me her recordings of her conversations with them. On Dec 7th they said they were sending her and mine out, but I didn't receive anything until second week in Jan...and that was only mine.

So once she has done that, I will gather all that, and submit to the Ombudsman. To me it looks like it's their medical teams review of her medical notes, against the Ombudsman take on the same. What you or your GP/medical team say doesn't get much of a look in.

antoinolachtnai · 07-02-2021 12:40am

First, be careful with the Ombudsman. The FS Ombudsman is not on your side. He is just a neutral arbiter.

Second, you need to frame things up more clearly.

The real nub of the question is what your relative would have been entitled to if they had not changed plan and remained on the old plan.

Is it the same, more than, or less than the entitlement on the new plan?

The whole thing seems to me to hinge around this issue.

If it is less than, then you would hope that your relative should still be entitled to whatever the lesser benefit would have been. (This may not be as simple as it seems however.)

There is also a complicated question about whether your relative was mis-sold the new policy. You will need to review the tapes very carefully.

You also have a point about a change in practice that occurred in the middle of all this.

There is also the argument about what a pre-existing condition actually is but it sounds like you have found out this is a tough point to win.

But your argument on each of these points needs to be very succinct and clear.

intothewest · 07-02-2021 12:56am

antoinolachtnai wrote: »

First, be careful with the Ombudsman. The FS Ombudsman is not on your side. He is just a neutral arbiter.

Second, you need to frame things up more clearly.

The real nub of the question is what your relative would have been entitled to if they had not changed plan and remained on the old plan.

Is it the same, more than, or less than the entitlement on the new plan?

The whole thing seems to me to hinge around this issue.

If it is less than, then you would hope that your relative should still be entitled to whatever the lesser benefit would have been. (This may not be as simple as it seems however.)

There is also a complicated question about whether your relative was mis-sold the new policy. You will need to review the tapes very carefully.

You also have a point about a change in practice that occurred in the middle of all this.

There is also the argument about what a pre-existing condition actually is but it sounds like you have found out this is a tough point to win.

But your argument on each of these points needs to be very succinct and clear.

Thanks so much for your feedback. Totally get what you are saying. Can you clarify what you mean by the 'change of practice that occurred in the middle of all this'?

If anyone has any advice how to structure the application to the Ombudsman, I'd appreciate it. Do I detail everything thing I have, and a timeline of events etc?

antoinolachtnai · 07-02-2021 1:14am

intothewest wrote: »

Thanks so much for your feedback. Totally get what you are saying. Can you clarify what you mean by the 'change of practice that occurred in the middle of all this'?

Sorry, I think I misread something you wrote. You referred to change of policy. I see now you meant what I would call a ‘change of health insurance plan’. All this terminology is important.

If anyone has any advice how to structure the application to the Ombudsman, I'd appreciate it. Do I detail everything thing I have, and a timeline of events etc?

You need to detail everything but that is really the background and back-up material. A chronology is really important for this type of work and you have to clearly link your evidence and arguments to it. You really need to clearly articulate your strongest points and put them to the foremost.

07-02-2021 1:30am

You have to fully exhaust the complaints procedure with the insurer before going to the ombudsman, otherwise he may send you back.

First we need to establish two things. Leaving aside the waiting periods:

1. Does her current plan cover the procedure in the particular hospital
2. Did her previous plan cover the procedure in that hospital.

If you provide the name of the plan your mother was on, and the name of the plan she is currently on I can try and help further.

You will have no joy whatsoever arguing that whether something is a pre-existing condition or not depends on when the patent became aware of it. They will go by the estimated date of onset which the consultant will provide. Whether your mother knew she had the ailment or had symptoms is irrelevant.

Shazamm · 01-03-2021 1:05pm

Xzavier Wrong Quitter wrote: »

You have to fully exhaust the complaints procedure with the insurer before going to the ombudsman, otherwise he may send you back.

First we need to establish two things. Leaving aside the waiting periods:

1. Does her current plan cover the procedure in the particular hospital
2. Did her previous plan cover the procedure in that hospital.

If you provide the name of the plan your mother was on, and the name of the plan she is currently on I can try and help further.

You will have no joy whatsoever arguing that whether something is a pre-existing condition or not depends on when the patent became aware of it. They will go by the estimated date of onset which the consultant will provide. Whether your mother knew she had the ailment or had symptoms is irrelevant.

Have you been in the same situation as you seem to have good knowledge on the subject?

01-03-2021 1:12pm

Shazamm wrote: »

Have you been in the same situation as you seem to have good knowledge on the subject?

Have not been in the situation myself, but have extensive experience dealing with health insurance on a professional basis.

Shazamm · 21-04-2021 4:27pm

any update on this

Health Ins Claim Refused

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