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Ash
Ash, Solicitor
Category: Law
Satisfied Customers: 10916
Experience:  Solicitor with 5+ years experience
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I have been working overseas and have had international health

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I have been working overseas and have had international health insurance with a British insurer for 21 years. (I should clarify that I'm not a UK citizen and am not in the UK.) In 2001 I had an operation to replace my aortic valve, which the specialists believed had been damaged by rheumatic fever when I was a child. The insurance company covered the operation as a "pre-existing condition" that had not been treated for two years. However, the operating surgeon discovered that the actual problem was a congenital bicuspid valve, and this was mentioned in the surgeon's report provided to the insurer. Although congenital conditions were excluded under the policy, the insurer did not raise any queries about this and paid for the operation. Since the operation, I've continued to pay premiums to the insurance company in good faith for a further 14 years. I've had no further medical claims in that time. Recently my cardiologist found that the implanted valve has deteriorated and needs to be replaced. I contacted the insurer, who told me that they could not cover the operation as it was for a congenital condition. They also said that they would not have covered the earlier operation if they'd known it was for a congenital condition. I feel that I've been led on by the insurance company, which had already covered this condition once and at no time indicated that they would not cover it in future, even as they accepted my annual premium payments. Under the policy, I can lodge a complaint with the Underwriters, and if I am unsatisfied with the result I can ultimately lodge a complaint with an Ombudsman in the UK. I need to have the operation this month and it is quite expensive. What chance do I have of getting the insurer to pay for the operation?
Submitted: 1 year ago.
Category: Law
Expert:  Ash replied 1 year ago.
Hello my name is ***** ***** I will help you.
Have you had a formal response from the insurance company back yet?
Customer: replied 1 year ago.
There has been some correspondence about my claim.1. When considering extending my policy in November last year, I was concerned at what seemed to be more stringent rules about existing conditions. I was assured that “If you need further treatment for a condition that we have already been paying for, then this will continue to be covered under the benefits of the cover level you have selected”.2. In December I applied for coverage of the operation and received a formal rejection letter on the grounds that mine was a congenital condition.3. I pointed out the reply that I'd received before renewing my policy, namely "If you need further treatment for a condition that we have already been paying for, then this will continue to be covered under the benefits of the cover level you have selected".4. I received a reply from a person signing herself as "Director". It said:"Regretfully I am unable to view the documents from your previous claim as these records are no longer available. We are only required to keep records for ten years.
"We do exclude all claims resulting from congenital conditions and therefore we are unable to meet the costs for your planned procedure as detailed in xxx's email.
"As far as I am aware this exclusion has always been in the policy and had we been aware this was a congenital condition the claim would have been denied."5. I asked them to reconsider, arguing along the lines that I set out in my question, namely, that my condition had been covered earlier and that they at no time had raised questions concerning the surgery, required the submission of additional information, or disputed the insurance payout, either during the claim process or at a later time. I was dissatisfied that I had not been given sufficient information to make an informed decision on continuing coverage with that company.6. My claim was again rejected, as follows:"The claim has been declined on the basis that it is a congenital condition and not on the basis that it is pre-existing. I can neither confirm or deny that this exclusion existed at the time although I believe it did and it has certainly been in existence for the last twelve years. As previously advised your previous claims files are no longer available so I am unable to comment if we were aware that this was a congenital condition.
"When providing renewal terms to our clients we always provide a document listing the key changes and the plan rules which clearly state there will be no cover for congenital conditions.
"I have taken advice from the Underwriter of the policy who advised they would be unable to provide cover on this occasion.
"Should you remain dissatisfied I can only suggest you follow the complaints procedure as detailed in the policy guide"According to the Policy Guide:a. If your question or concern relates to the administration of your Plan, or this Policy Guide: You should contact the Chief Executive Officer providing your Name, Certificate Number and full details of your question or concern.b. If you wish to make a formal a complaint relating to a claim under your Plan you may do so at any time: You may refer the complaint to the Complaints Manager at xxx Insurance Company (UK) Ltd.c. If, after exhausting all of the above methods, you are still dissatisfied with the outcome of your complaint, or you have not received a response within eight (8) weeks, you may have the right to refer your complaint to the Financial Ombudsman Services.That is where I am at the moment. I'm planning to start the process but I'm not sure how to proceed. My cardiologist and surgeon have indicated that they are willing to write a letter. I understand that they are likely to approach the issue from the medical angle (about the congenital nature of the condition) but need to confirm this.
Expert:  Ash replied 1 year ago.
So it appears they covered it without knowing?
Customer: replied 1 year ago.
I think the situation is this:They were informed that my condition was congenital but failed to notice it.They now maintain that "had they known it was congenital they wouldn't have covered it".My position is that they are making me pay for their own failure to notice this information. Had I known that they wouldn't cover the condition, I wouldn't have continued using them.They are hiding behind 1) the letter of their policy and 2) the fact that they don't keep records...I'm not happy with this.
Customer: replied 1 year ago.
Yes, I think you can say they covered it without knowing it. The problem is that the congenital nature of the problem only became apparent during the operation. But they definitely received the surgeon's report.
Customer: replied 1 year ago.
Sorry, I should point out that they rejected my claim this time AFTER receiving a report from my cardiologist, who pointed out that it was a bicuspid aortic valve. It seems this was the first time they realised the problem since the operation in 2001.
Customer: replied 1 year ago.
It's getting very late here; I'll have a look tomorrow morning.
Expert:  Ash replied 1 year ago.
Sorry for the delay I have been travelling back on the train.
When did you have the first operation?
Customer: replied 1 year ago.
May 2001.
Expert:  Ash replied 1 year ago.
Ok. It's not unreasonable for them to have destroyed the paperwork. The law says they should keep documents for a reasonable time which is accepted as being around 5 years. If it does not exist given its over ten years they can't be criticised for that.
In relation to insurance, it's unfortunate that they paid out originally. But in terms of contract just because they paid out then, albeit accidentally does not mean the law says they should cover you now. In find if it was a mistake they can rely on that during this current claim.
If there is a clause which says that they do not cover congenital conditions then sadly you can't make them. It is for you to check to make sure the policy is suitable every year.
So therefore you should go to the Ombudman, but as someone who does not live in the uk, I can not say for sure whether their remit would covet you.
But Ombudman is first and then court if necessary. But I am not sure as to the prospects given the mistake.
I am sorry if this is not necessarily the answer you want and certainly not the one I want to give you, but I have a duty to be honest.
Can I clarify anything for you about this today please?
Alex
Customer: replied 1 year ago.
Regarding jurisdiction:Unless specifically agreed to the contrary the contract of insurance shall be governed by the laws of England and Wales and subject to the exclusive jurisdiction of the courts of England.My main complaint is that I have been paying premiums in good faith for 14 years. There was no indication from them that there was a problem with my earlier claim, or that they would fail to cover future claims.I understand that it is for me to check that the policy is suitable. By the same token, I feel that it is also incumbent on them to inform me if there is a problem with my policy that would invalidate future claims for that same condition. The fact that this was a congenital condition has never been hidden on my side. Had they indicated that any future replacement of the replaced valve would not be covered, I would have looked at other options.I assume from you answer that I have no legal resort on this matter.
Expert:  Ash replied 1 year ago.
The only claim you could have is for breach of contract. You could potentially argue by covering the earlier claim it was implied into the contract that it covered you.
I think the only difficulty for that is the renewal. They could argue that it's a new contract year on year and any obligation ceases at the beginning of the renewal period.
It's worth a shot but I think it would be an uphill task. Not impossible, just hard.
Does that clarify?
Alex
Customer: replied 1 year ago.
I realise it's getting late there, but their email of October last year does imply continuity of contract:"The underwriting terms applicable to your plan would have commenced on your inception date which was 29 November 1994.
"Any condition that was in effect prior to this date will be classed as pre-existing. If we have paid for treatment for conditions that have arose since your start date then these are not classed as pre-existing.
"If you need further treatment for a condition that we have already been paying for, then this will continue to be covered under the benefits of the cover level you have selected."My final question: Given that you feel that it would be "an uphill task", what kind of costs am I looking at for taking this to court?
Expert:  Ash replied 1 year ago.
Ok. Ombudman is best as it is free. To take it to court probably looking at around £15,000
The paragraph you highlighted does help and make it stronger for you, Ie more realistic to win.
Does that help?
Alex
Ash, Solicitor
Category: Law
Satisfied Customers: 10916
Experience: Solicitor with 5+ years experience
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Customer: replied 1 year ago.
Thanks, ***** ***** appreciate your help.The operation will cost £25,000 - £30,000. I've probably already paid at least that in premiums over the past 14 years (this insurance isn't cheap). Another £15,000 could amount to good money after bad. I'm almost ready to retire and I don't want to waste the funds I have. I'll have to think about it.I do have other options but they could be disruptive of my future hopes and plans.Greg
Customer: replied 1 year ago.
I should be more specific. I can make a statutory declaration that I'm back in Australia to stay, which will entitle me to Medicare coverage. But this will commit me to staying in Australia and not going overseas again after the operation. I will obviously have to choose this option before I go for the operation. The Ombudsman will take some time (I may have to wait eight weeks, according to their wording). Given that I need to have the operation in the near future, I may not have time to choose this option.Thanks again.

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