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F E Smith
F E Smith, Advocate
Category: Law
Satisfied Customers: 8443
Experience:  I have been practising for 30 years.
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I have been in email contact with my PMI insurer regarding a

Resolved Question:

I have been in email contact with my PMI insurer regarding a claim in respect of a number of consultations I had to undergo in Ireland following an incident. Initially, they point blank denied my claim for a number of reasons, one of which was that my consultant was not on their list despite my not informing them of his name. They now say there is no such list. I suspect they are operating a "blanket denial" policy and am curious to know how many others have had legitimate claims denied. Am also wondering whether they are breaching the FCA's TCF guidelines.
Now, after many emails where I've quoted the T&C's of the policy, they've offered to cover eight out of the twenty consultations - €600 as opposed to the €1,600 owed. Cleary this indicates that they now accept responsibility for the claim, despite the many early denials. The issues are as follows:
- They are using an FX rate based on the date of the original incident in January (which is clearly more favourable to them) rather than the current FX rate. The twenty consultations took place between Jan 2016 and July 2016. What does the law state on what FX rate should be used in this situation?
- They are only offering to cover eight of the twenty treatments. Their reason is that is it not the "intention" of their emergency overseas cover policy to cover a long period of treatment, despite the only limit in the policy conditions being an annual limit of £1,500.
You will need to read the policy conditions, email correspondence and doctor's report which I can forward on.
Hope you can help.
Submitted: 2 months ago.
Category: Law
Expert:  F E Smith replied 2 months ago.

Were you living in Ireland? What was the reason that you were in Ireland for and why did these consultations take place over a protracted period of 7 months?

Did you get authority from them before you undertook a protracted number of consultations?

Why were there so many consultations?

What was the nature of them?

May we have the part of the terms and conditions which is relative to this please?

Is the issue that they are saying that the consultations you have had are beyond the scope of emergency treatment?

The question then arises as to what the difference between emergency treatment and normal treatment? Would they be expecting your return to the UK for ongoing treatment?

Have you reported this to FOS?

Which provider is it?

Customer: replied 2 months ago.
Hi,Might be best if I forward on the email exchange, doctor's report and terms and conditions as this should answer nearly all your questions. Do you have an email address I can forward these to?RegardsShane
Expert:  F E Smith replied 2 months ago.

We are not allowed to accept documents outside the site unless it’s part of the premium service exchange for which there is an extra cost. You can attach the documents on here.

Customer: replied 2 months ago.
Please find all documentation attached along with pdf of email exchange. The sections of the T&Cs that are important are the Overseas Emergency Medical Expenses section along with the General Exclusions. Given they have now made an offer (to cover eight sessions) I suspect the latter may not be relevant as they have essentially admitted they are liable by making the offer. I want to claim for all 20 sessions. As you can see the lady says it is not their "intention" to cover consultations over a long period but the T&Cs do say that they will ongoing treatment by a consultant up to a maximum of £1,500pa (there is nothing in there about a limit of eight payments).I also need advice on what exchange right should be applied (date of incident, dates of treatment or date of payment of claim) - i.e. what does the law say about this?Any questions let me know but you should have everything you need now hopefully.ThanksShane
Expert:  F E Smith replied 2 months ago.

Thank you.

I still don’t know why you were in Ireland for 6 months.

They say in the email of 6 June at 0837 that the psychiatric treatment is not covered under the overseas emergency plan provisions but it certainly isn’t excluded and hence it would be covered.

They are Incorrect in the first email they sent.

It comes down to whether this is emergency treatment or not.

I don’t think they’re offered to pay €800 is an admission of guilt. I think it’s a genuine offer to settle.

The difficulty here is that it’s unlikely that emergency treatment be spread over 6 months because the first treatment was 20 January and the last one was 11 July. I don’t think the judge would find that psychiatric treatment over seven months for a nervous breakdown was emergency.

On a no interpretation, that is not emergency, that is a protracted course of treatment.

There is one thing that would help you and that is that if you got a consultant to give evidence which confirmed that it was essential that your treatment was carried out with the same therapist without travelling home. Without that, I don’t think you have a good chance of succeeding certainly in court.

If you take them to court on this, I don’t think that you have a good chance of success although it would be Small Claims Court and therefore even if you must, you would only lose the court costs and have to pay any nominal solicitors costs of the insurer. I would not go to court with the hope of 50% chance of winning. It is not the treatment of the nature of the treatment the protracted timescale.

What you might want to do is make a formal complaint to the Financial Ombudsman Service and let the Ombudsman decide. I will tell you that they will not routinely come down on the side of the insurer.

I’m sorry the answer is not more favourable for you.

Can I clarify anything for you?

Customer: replied 2 months ago.
Hi,I went to Ireland on holiday over Christmas and had the breakdown there before I was due to return. Am Irish and was staying with my family. My GP advised that I should take time off work and that it would be better to have the support of my family during this period which is why I stayed there for treatment.My consultant would be happy to say in court that it was essential the treatment be carried out by him.The breakdown was obviously an emergency an it was urgent that I got help. I was advised not to return to the UK or to work until my GP and consultant felt I had fully recovered, hence the length of the treatment. Given it was an emergency that I got help quickly, is the length of the treatment a major issue?Also can you clarify what the law states on the exchange rate to be used to settle claims abroad i.e. what date should be used.ThanksShane
Expert:  F E Smith replied 2 months ago.

Remember that you are entitled to a have a work colleague union representative at that disciplinary meeting as well as your interpreter.

You could email the Data Controller to ask how this could have done wrong and what the ramifications are of any breach.I wish I could give you the answer you wanted but I just don’t think the facts are favourable. Sorry

Customer: replied 2 months ago.
Sorry? I presume that answer was meant for someone else?!Shane
Expert:  F E Smith replied 2 months ago.

I apologise for that. It was indeed. It happens from time to time. Here is what you should have received:

It not have to be your consultant that would say that, but an independent. Your consultant has a vested interest.

It might be “better” but not necessarily essential and it comes back again to whether this is classed as emergency treatment ongoing therapy.

I accept that the breakdown was emergency but it’s the ongoing treatment that you have to convince the insurance company but was emergency and it’s because of the protracted period of time that is problematical for you. You would not normally be fully recovered after emergency treatment because it would need some ongoing treatment.

I think that it’s the length of the treatment that is the whole issue.

The doesn’t say anything about which exchange rate is to be used because there was no statutory provision in that respect.

It may well be that the cost arguing the difference in exchange rates is going to be far more than you are arguing over. What the world does say is that the idea of insurance is to put you back into the position had the incident not occurred and hence, it is what exchange rate is required at the time the money is handed over to you to put you into that position.

I wish I could give you the answer you wanted but I just don’t think the facts are 100% favourable. But I would certainly make a complaint to the Financial Ombudsman Service because it is risk-free. I just don’t want you to build your hopes up. Sorry

F E Smith, Advocate
Category: Law
Satisfied Customers: 8443
Experience: I have been practising for 30 years.
F E Smith and other Law Specialists are ready to help you
Customer: replied 2 months ago.
Ok, have emailed demanding the full amount and bulleted my reasons why they might be known breach of TCF. Told them the FX rates should be those as per each date of treatment to provide full redress for the amounts I handed over on each date. Will see but would rather fight than accept a token offer. Will give you a good rating. If you want to know how it goes you have my email.Thanks for your help.Shane

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