To think my insurance should cover me nearly dying?!

[octavio1996]

Posting here because I’m at my wits’ end and don’t know what to do. Currently stuck in Australia after a total nightmare and my insurance company is refusing to pay out.

Basically, I was travelling here on holiday with DH and the DC (two teens, one younger), having an amazing time. Then out of nowhere, I got really ill massive pain, collapsed, rushed to hospital. Turns out it was a ruptured appendix and I ended up in intensive care for days, genuinely thought I was going to die. DH was beside himself, kids were terrified. The hospital care was amazing but obviously, this is Australia, and the bills are absolutely eye-watering.

Here’s the kicker: my travel insurance is now refusing to pay. They’re saying it’s a “pre-existing condition” (it wasn’t), or that I didn’t declare something minor from years ago that has nothing to do with this. I’ve been on the phone to them constantly, but they’re just fobbing me off. We’ve already had to put thousands on a credit card just to get me discharged. We were meant to fly home next week, but I’m not even sure I’m well enough to travel, and obviously, we can’t afford to stay indefinitely.

Has anyone been in this situation before? Do I have any chance of fighting this, or are we totally screwed? DH is trying to stay calm for the DC, but I can tell he’s panicking too. I just want to go home and not be bankrupt.

TL;DR: Nearly died from a ruptured appendix, travel insurance won’t pay, stuck in Australia with a huge bill. Help!

This is what worries me. There can't be a person one country who hadn't had a vague issue that never got diagnosed as and I don't know what a doctor even made as a diagnosis if any.

So genuinely what do you put on the form? I scraped my knee when I was seven and have a scar?

The problem is that it doesn’t matter whether the IBS symptoms are linked to the current issue. Insurance companies ask you to declare everything and will refuse to pay if they find you’ve been dishonest.

Whether this particular case will be upheld by the Ombudsman is anyone’s guess - OP will have to go through the formal complaints procedure before the Ombudsman can get involved.

Fortunately the Ombudsman also takes the view that it's ridiculous to expect people to remember every cough and cold

Absolutely, @anyolddinosaur, and while every case will vary that's why I mentioned it's nothing new for the Ombudsman to overturn an insurer's decision

As for the "insurance included" thing with the banks, as said before they don't ask about existing conditions because they don't need to. Somewhere on the account application form there'll be a "T&Cs accepted" box to click and those T&Cs will probably say existing conditions are excluded from the insurance portion - and whille many don't read T&Cs that's no skin off the bank's nose

Look on your medical records and declare what’s on there.

The costs of doing so would push up everyone's insurance premiums and would probably cripple the NHS whose staff would be inundated with requests for millions of peoples' medical records. It's clearly not a good idea. Far better for insurers (and the NHS) to just trust policyholders to be honest and then not pay out when it turns out they weren't!

It would also cause delays to people taking out a policy. At the moment, you can take a policy literally a few minutes before your holiday, but if the insurer needs to ask for medical records from the NHS, you're realistically going to have to apply for the policy several weeks ahead of your holiday.

And how do comparison websites work? Will each different insurer all have to ask for the NHS records before they give you a quote. So each GP surgery gets potentially 10/20 requests from lots of different insurers.

You've really not thought it through.

OP you seem to be focussing on the insurance and ignoring the very good advice from several PP's saying that this should all be covered by the reciprocal heathcare agreement between UK and Australia. You need to register with Medicare, but then the majority of costs will be covered. You can register with Medicare now, even after your treatments. The only reason I can think of why you might not be covered by Medicare is if you were treated in a private hospital. For clarity, please can you confirm if the hospital was private or public?

IBS can’t be diagnosed; only suggested after other tests rule out other possibilities.

I'm sorry to hear you are going through this, OP. Insurance companies can be an utter disgrace, as I have said many times before on these threads where people are quick to condemn others for not having adequate travel insurance.

The OP has done all the right things and yet still they are not paying out.

Well, she did have an appendix...

J/K.

OP, there should be an appeals process, I would look into that.

Try Rip Off Britain on BBC1. They are very good with cases like this.

I think it depends on what they asked you to declare. Did they ask you if you have ever had any stomach issues?

Another thing to bear in mind is that even if the proposal was found to be sound, there is an onus on the insured person to limit their liability/costs, so using a private hospital when they could have used a cheaper/free state hospital could also result in refusal to pay out.

How the fuck would you know or be able to choose in an emergency?

But the issue comes down to what is a pre existing condition.

i have been to the doctor with a litany of ENt problems. All have come back as benign. I just have an awkward head! 😅 nothing is very serious, just annoying at times. Absolutely no pre existing condition to report. I am officially suffering from nothing whatsoever. What do I need to declare?

It might not have been IBS. Is there anything in your records that subsequently suggests a different reason for the symptoms? You can request your data from your surgery to be sent by email or I think some data may be available online in England. Scrutinise what is on it and tell them if it was never diagnosed and was subsequently found to be wind or whatever. Also, there is no link between the 2.
The process if they continue to refuse is then time consuming and you may have to bite the bullet. You can take it through the complaints department of their underwriters and if they still refuse you can then go to the Ombudsman. Their decision is likely to be final even if you are inclined to take it to court you won't get far if the Ombudsman finds against you.
Personally I'm horrified at the number of times insurance companies refuse to pay out and the Government should do something about it. Can you get your local MP on board?
You have my sympathies but brace yourself for 'the long game'.

I had insurance through I think Avanti, I ended with my first ever UTI and fever about a week before we were to go away, I could not stand I was in so much pain never mind go on holiday. I ended up in A&E with suspected sepsis but would they pay for the missed holiday? would they hell I lost £2500

They said that I should have seen my GP who would have said if could go on holiday or not but you cannot see a GP, specially not for UTI 😬

I do not bother with insurance now they take your premium but not pay out, I just go without

There is genuinely some evidence that people suffering from IBS and other chronic bowel conditions do indeed appear to be at an increased risk of going on to develop issues with their appendix, however I don't think that's why they have refused this claim. I have a feeling they are using non disclosure of previous investigations, but I don't think it is right or fair.

How many of us declare that we take the pill, have a coil etc? Maybe you don't need to if you get the over the counter one you pay for, but do if you get one that's prescribed. Absolutely bonkers.

I'm genuinely confused, how far back are we expected to list complaints?

If you went to the doctor in 2001 complaining of feeling nauseous is that going to be on your records and affect a claim?

I recently added HRT to my insurance as I saw the story about the woman with a brain tumour, but never would have thought to ...

All these smug people saying 'well you do need to declare everything ya know' are speaking from a position of not having anything like this happen to them. I bet you've got vague medical bits you've forgotten about too.

I think the layperson would reasonably expect appendicitis to be covered unless they were specifically diagnosed with a grumbling one beforehand.

If I broke my leg I wouldn't expect insurance to decline it based on also having hayfever.

It's awful.

I don’t think people are meaning to be smug - many of us are just going off our own experiences or those of friends and family.

I personally know someone who was denied an insurance payout based on non-disclosure so I’m extra paranoid about declaring things now.

I can't see how they can turn you down for not having IBS. You went with bloating- you were tested and didn't have a diagnosis of IBS.
They are totally at it- refuse you for non disclosure in the first instance and hope you don't chase it. You need to be clear you are fighting it.

Hi OP

As a general rule they can only decline a claim if they can prove that if the full medical history had actually been disclosed, their underwriting guidance is to decline to insure you, or insure you but exclude various conditions that they would deem to be related including appendicitis.

Have they done this? If the claim goes to the FOS then this is what they're likely to look at. If it turns out that they would have insured you but charged more premium or changed the terms (something like an increased excess) then the FOS is likely to rule that they should apply these terms retrospectively.

Try not to panic. Have a really careful look what they asked you for when you signed up. Usually it's any doctors appointment in the last x years, hospital stays, pre existing conditions. It if was any doctors appointments then it's a bit more tricky.

Also Google the insurance act and innocent misrepresentation. There is a difference between someone who concealed something deliberately (committing fraud) and someone who didn't disclose something as it didn't seem to matter. The onus is on the insurer to ask you very clear and specific questions. If they had just asked you about pre existing conditions then I'd say that not clear as it's not a 'condition' assuming you weren't formally diagnosed and have had ongoing symptoms.

If I was you I'd be asking one of my friends if I could use their details to get a quote (giving a different phone no eg one of your kids, that won't flag on their systems) and change the answers to fully disclose all the info on the potential IBS. This might give you a clearer idea on where you stand / insight into their underwriting process, and also potentially give you some evidence that they are acting unfairly (if they would cover a new person)

Might be worth threatening to get social media / news sites involved

Good luck and please update the thread if you want any more specific advice

Obviously depends on the circumstances. But once you're stabilised after being blue-lighted, there can be opportunities to take stock of what's happening, what's needed, etc. Even after an operation, you can usually "choose" to continue where you are for convalescence and recovery, i.e. stay where you are, or get transferred out somewhere else. I think the insurance would look at the chain of events, urgency, options, etc. The basic premise under law is that you have to minimise your costs as far as you are able. If you're not able, then fair enough. But if you make expensive "choices" then you bear the potential consequences. I think the insurer would be interested in the chain of events that left the OP getting treated in a private hospital rather than a state hospital. I.e. was it a "blue light" emergency admission, what it a life or death emergency operation, etc - very different to if she'd walked into a private street corner clinic complaining of stomach pains and had the operation a week later!

It's like if you have a car accident that's not your fault. You can claim a "like for like" hire car, but you can't claim a Porsche hire car if it was your Nissan Micra that got pranged (unless the Porsche was the only hire car available when needed!).

This is very good advice. Also your local MP could intercede on your behalf when you get home- there is a potential public policy issue at stake here.

Also clearly state in writing the mental distress this is causing you and tell them you want to make a formal complaint (after you have all the info)