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F E Smith
F E Smith, Advocate
Category: Law
Satisfied Customers: 8718
Experience:  I have been practising for 30 years.
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I had an operation on my Knee in Febrauary. I thought at the

Customer Question

I had an operation on my Knee in Febrauary. I thought at the time I was covered by my employer insurance. When I called the insurance company I was given an authorisation code for the surgery. 2 weeks after the operation I received a bill from the hospital for £2020 plus a bill for £800 from the surgeon and another £300 from the anethnetist. I contacted the insurance company and was told my company cancelled the policy 2 weeks after my operation but backdated it to the 01-01-2016. Am I liable to pay for this.
Regards
Steven Hamil
Submitted: 6 months ago.
Category: Law
Expert:  F E Smith replied 6 months ago.

Which insurance company was this?

On what basis did they cancel the policy them backdate it?

If we could have the details, it would be helpful. Best wishes.

Customer: replied 6 months ago.
I was made redundant from the position in December. The treatment was already ongoing at this time, I had already had an MRI scan and 2 appointments with the consultant. I was not sure at the time if the policy was still valid for the operation on 2/02/2016 but when I contacted the insurance company they said I was still covered and they gave me the authorisation code for the operation. Then I was informed 2 weeks later that the policy had been cancelled on 16/02/2016 by former company but they wanted the cancellation backdated to the 01-0112916
Customer: replied 6 months ago.
Sorry the insurance company was CIGNA
Expert:  F E Smith replied 6 months ago.

They are a large and ethical insurance company.

Whether you are liable for these extra costs depends on firstly the authorisation you were given which in my opinion, you can rely on and secondly, if, when you leave a company, the insurance company is allowed to leave you hanging without funding, in the middle of treatment.

In that respect, you would need to check the terms and conditions of the scheme in fine detail.

When you have checked the conditions of the scheme in fine detail, then if this is covered, that you know where you are, you are arguing with the insurance company making a formal complaint and if necessary referring the matter to the Financial Ombudsman Service. If however it’s not covered, you are still going to make a formal complaint to the insurance company because you relied on what you were told that you are still covered in if they still say that you’re not covered, then make the complaint, once again to the Financial Ombudsman Service.

Can I clarify anything for you?

Please don’t forget to rate the service positive. It’s an important part of the process by which experts get paid.

Best wishes.

FES.

Customer: replied 6 months ago.
Hi
Would it be possible to send you a copy of my policy by email for you to look at and advise me further.Best Regards
Steven Hamil
Customer: replied 6 months ago.
Sorry if there has been a misunderstanding but I have not said that I am not satisfied with your reply. I have been looking through all my mails to locate the policy for your review
Expert:  F E Smith replied 6 months ago.

Thank you. I appreciate the negative rating was a mistake. You can rate positive whenever you wish we can still exchange emails.

I think you would be a good idea if you let me have the policy if you can. Thank you.

Customer: replied 6 months ago.
Ok can you give me an email to send it to please
Expert:  F E Smith replied 6 months ago.

You can attach using the paperclip icon

Customer: replied 6 months ago.
Please see attached I hope this helpsBest Regards
Steven
Expert:  F E Smith replied 6 months ago.

In the Helpful booklet, it refers to pre -authorisation and clearly, your expenses were pre-authorised because you rang them on 2 February and they told you that you were still covered. They cannot backdate the cancellation just because it suits them.

There is and the Core Plan which for the majority of treatments it says that the benefit limit-Paid in Full. To me, that would say that a claim is then paid in full. There is nothing anywhere in those documents about leaving the scheme partway through treatment.

You need to raise a formal complaint with them following the complaints procedure detailed in their documentation and then, if they have not given you a satisfactory response within 8 weeks, make a further complaint to the Financial Ombudsman Service.

You can of course sue the insurer in court but that’s going to be expensive risky and time-consuming because you may not win. The Financial Ombudsman Service is free and it is impartial.

Can I clarify any points arising from this?

Customer: replied 6 months ago.
HiThanks for the information you have provided. It now sounds like they may after all be liable to cover the cost. It has been a very worrying few months for me as I personally can not afford to pay for the cost of the treatment. Would it be possible for you to write the letter for me. I realise that there will be a charge for this and would not have a problem paying you to do this on my behalf.i can provide you with my details including my Cigna membership number.Best Regards
Steven
Expert:  F E Smith replied 6 months ago.

I can give you the wording of the letter to cut and paste into your own letter but is not something which I could take on as an ongoing legal case for you.

I will submit a premium services proposal for you and then we can exchange emails offline for confidentiality purposes.

I will need you to let me have whatever correspondence, emails etc you have from them.

F E Smith, Advocate
Category: Law
Satisfied Customers: 8718
Experience: I have been practising for 30 years.
F E Smith and 2 other Law Specialists are ready to help you
Customer: replied 6 months ago.
Ok I am happy to do that. All the contact I had with Cigna was by telephone every time I needed an authorisation code I would call them and they gave me it over the phone. My membership number was *********** and the 2 authorisation codes were###-##-####and###-##-#### ***** of the codes was the MRI scan which they paid and the other was for the hospital stay, anethnetist, operation and to see the consultant which the refused to pay
Customer: replied 6 months ago.
Hi did you manage to do a letter for me to send to the insurance company
Expert:  F E Smith replied 6 months ago.

I am sorry, it slipped through my system.

I will send you my contact details. Please send me an email and we will exchange emails privately off-line.

Customer: replied 6 months ago.
My email address is***@******.***
Expert:  F E Smith replied 6 months ago.

I just sent you a test email. If you can just reply to that, I will send the letter over for you. We can then exchange emails regarding this in private.

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