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!

Is it AXA, by any chance? They are the most disgusting company I have ever had the misfortune to deal with. They made a traumatic emergency situation abroad a million times worse. And then were just as bad when we got home and had to recover expenses.

How can you remember every little thing though? Remembering you had cancer is one thing but remembering you mentioned you had constipation once or a sore big toe twenty year’s ago seems a bit much.

I don’t understand why it’s a non declaration if it’s outside the time limit they ask for … say two or five years? I had childhood chest/wheeze issues. I’ve not had any antibiotics ( for anything) or inhalers for 25 years at 45. I would not disclose it as it’s more than 5 years ago. so how would that be a non declaration? It’s ridiculous. No one remembers everything they see a doctor for in decades especially with non follow up/further treatment.

Insurance companies seem to seek anyway to get out of paying.

I haven't read the whole thread so apologies if this has already been covered.

I always buy travel insurance over the phone so I'm always talking to a human being. All you need to do is to answer the questions they ask accurately and truthfully. Nothing more.

So I get asked if I've ever had any heart related medical issues and if I've had any other medical conditions treated or diagnosed in the last 12 months.

Those are the questions they (Saga) ask and those are the questions I answer. Apart from heart related issues they don't seem to want to know about anything you haven't consulted your doctor about or been treated for in the last year. I've even volunteered information and they've been quite clear that if it wasn't in the last 12 months they don't need to know.

Unless the OP has simply gone out and bought travel insurance on the basis of "what's the cheapest out there" rather than "what's the best I can afford" I find it difficult to believe that her insurer would nit-pick on symptoms from years ago that never resulted in a diagnosis and which were irrelevant to the current health emergency.

Apart from that I wish her good luck and agree she needs to make a formal complaint against her insurer and follow it up with a complaint to the FSO if necessary.

NB1 - I'm not saying this is the case with the OP so don't shoot me down, but if you are buying travel insurance it makes no sense not to truthfully and comprehensively answer all the questions you are asked and to "forget" something. Your insurer will find it even if you've "forgotten" it.

NB2 - the OP's previous symptoms of possible IBS from years ago are obviously not relevant to her current problem so her insurer should not be able to rely on them for not paying out. (Well I say that but I'm not a doctor. Maybe possible IBS symptoms from years ago do indicate that you'll get appendicitis down the line. All the more reason to buy over the phone and answer only the questions you are asked. If the questions are unclear, ask for clarification)

Ditto here. We're paranoid about disclosing absolutely everything. We both have chronic conditions, but not only do we fully disclose those, we disclose absolutely everything else too. These days it's easy as it's usually just a very long online questionnaire where answering a question leads down a rabbit hole to lots of other questions. It's a pain in the neck, but it's necessary. Either one of us could end up with enormous hospital costs if our condition worsens whilst abroad, so we have to make sure we're fully covered for hospital stays, repatriation, etc. The cost is usually only around £50 more per person, so it's not the cost that's the issue, it's the time and effort in making the declarations.

We also research the country(ies) we are visiting to see what reciprocal health care agreements are in place and what free/subsidised healthcare would be available if necessary. Usually a quick Google leads you to their website which gives an overview of what's available free/subsidised, and what isn't. Good to know so that you can make informed decisions if something does go wrong. Just before Covid we went to Russia, so were absolutely paranoid that we knew exactly what their healthcare system looks like and what to do/where to go if either of us became ill. I think it's vital to do research if you're going anywhere other than the EU as you can't make assumptions about healthcare systems in other continents!

Also your policy should have a complaints wording somewhere that should set out the process.

But main advice is look at exactly what you were asked for and whether this could reasonably have been expected to include the info about IBS.

Also ask your doctors for a copy of the notes (were you considered formally diagnosed? Was this ever formally communicated to you? This is different to 'if it doesn't get better it might be this...' which implies that as it did get better, it wasn't this)

You just answer the questions they ask. From memory, the online questionnaire doesn't ask about ALL GP appointments going back to year dot. They ask for current medication, "recent" GP appointments/consultations/tests etc (they specify the timescale), and ongoing medical conditions, any ongoing undiagnosed conditions under investigation/consultation, etc. If you answer honestly, whether you think relevant or not, they've not got a leg to stand on. You just have to be careful to read the questions tell them exactly what they're asking. Unfortunately it seems a lot of people don't read the questions properly and that's when the insurer can refuse to pay out.

My OH was diagnosed with cancer around 7 years ago. We had two "big" holidays booked which had to be cancelled because he'd be in the middle of 6 months of chemotherapy for the first holiday and would be in hospital for a stem cell transplant for the second holiday at the end of the year. Both insurers paid out with no quibble at all - claims for thousands of pounds as these were expensive holidays for the entire family. He'd declared numerous visits to the GP in the two years' prior, for fainting, heavy bruising, painful bones, etc - the GPs basically fobbed him off and just said it was natural ageing, so OH "could have" shrugged and left them off the insurance proposal. But he included them. That's exactly why the insurer paid out - everything he'd consulted the GP about pointed to his bone marrow cancer, but because he'd declared it and the GP records showed they'd basically not diagnosed anything and told him it was nothing, they paid up as it wasn't OH's fault the GPs were useless!

When I mention smugness, I'm referring to the people who are saying 'but of course you should have done xyx', almost gleefully.

Regardless of how things are, I think it is unreasonable for insurance companies to decline to cover an incident that is clearly not linked to any other health situation.

You are insured… until you come to claim.

Absolute scammers

This will get lost but hopefully you see it.

Insurers are not allowed to decline a claim on the basis of misrepresentation (I.e. not declaring previous history) if that misrepresentation does not prejudice the claim (I.e. make it that you would be uninsurable). They could charge you a high premium but they can't decline the claim outright.

Make a complaint to the insurer (you can't go straight to the FOS until either the insurer has replied or 8 weeks has passed). State that declining the claim on the basis of ibs not being declared is an unfair term and the ibs did not affect the appendicitis and therefore has not prejudiced the claim.

It'll take a while but you should get the claim overturned.

P.s. next time. Declare everything!! Even if it seems inconsequential.

Yep, agreed but it’s one of those situations where you have to play the game, no matter how much you disagree with the rules.

Reciprocal Health Care Agreement (RHCA):
Eligibility:
UK citizens visiting Australia are eligible for medically necessary treatment under Medicare.

What's Covered:
The RHCA covers essential and urgent medical care, including:
Medically necessary treatment outside of a hospital.

Medically necessary treatment as a public patient in a public hospital.

Certain prescription medicines under the Pharmaceutical Benefits Scheme (PBS).

What's Not Covered:
Pharmaceuticals (unless you're in hospital).

Ambulance services.

Medical evacuations.

Dental treatment.

Pre-existing medical conditions.

People who are not registered as visitors (e.g., those studying in Australia).

Routine medical treatment

1. Medicare Enrolment:

How to Enrol: You can enroll in Medicare at a local Medicare service centre before or after your treatment.

What to Bring: Bring your passport and a valid visa.

Id hand it over to the hospital & let them charge it through insurance

As for what to do next I don't know how you'd go about escalating it. Unfortunately

if you look at the policy, it should say somewhere that you need to declare all medical conditions, doctor visits etc. I did this the first time I used the travel insurance with my bank (Barclays) and I update it every time I book a holiday, or annually, whichever comes first. They then send me a copy of everything I’ve disclosed.

Exactly, 30 years in Australian health care and administration and I can’t understand how you are expected to pay (unless you went to a private hospital).

How long is 'years ago' OP and in what context do the IBS symptoms appear in your medical notes?

A potent vindaloo can cause 'IBS symptoms', but if you've had multiple investigations/referrals over it, they may consider this 'ongoing' if it's fairly recent.

Ask for it to be reviewed by the insurance's firm's Chief Medical Officer / complaint adjudicator team as a matter of urgency due to your situation and state that you will be referring to the Financial Ombudsman Service. Ask them to also raise a complaint with their CEO. This normally brings more attention to your case.

Unless there is some Government help or the above process progresses at a very speedy rate, I think the likely scenario is that you will be asked to pay your medical bills before leaving Australia and you will have to fight the Insurance Company when back home to reclaim the cost (if successful on appeal).

I would also put in a Subject Access Request (SAR) to the Insurance Firm to see what exactly they are holding on file regarding your medical conditions, etc - this will help with your appeal to the Financial Ombudsman Service if needed.

When a claim is made the travel insurer asks for a GP report. The IBS stuff was obviously showing on your GP records and any investigations you had or they wouldn't know about it. You didn't declare it. Whether it is relevant to appendicitis or not isn't the issue. EVERYTHING needs to be declared when you take out travel insurance within the time period asked eg 2 years 5 years etc, GP visits, any meds taken, any investigations etc.

Get a copy of your application form, see what the time period was. then get a copy of your GP report and see when IBS was last mentioned. You need specific details of dates etc to ahve a successful appeal.

Or if it is showing on your med records withing the last x years which the proposal form asked for then they are right to reject.

Exactly - why involve travel insurance

You will probably need to discuss this with the ombudsman once you are back home . It’s an awful position to be put in and I’m truly sorry 😔. We had similar ( not as bad as you ) a few years ago when one of the kids had chicken pox . They told me it was my fault a si knew she didn’t have it before . I off course didn’t let them get away with it but took a while for tem to pay back all expenses .
Hope you are feeling better soon

@Badbadbunny But her mentioning a possible IBS (because she had some bloating) five years ago, that came to nothing, would surely not be logged on that form as currently under investigation? I recently went to the doctor worried about a mark on my skin. She told me it was nothing, am I supposed to mention that in five year’s time on an insurance form?

Insurers are total cunts. They will do anything in their power not to pay out.

Everyone gets digestive issues. Having some bloating and a dicky stomach five years ago that was not diagnosed as anything should have no relevance on her insurance claim, in my opinion.

On the back of this thread I’ve just rung my insurance company to declare a diagnosis of diverticula disease from years ago. They asked if I’d seen a dr about in the last 12 months, or taken any medication, and when I confirmed I hadn’t, they said it’s irrelevant, I don’t need to declare it and they are only Interested in conditions arising, being investigated or that I’m taking medication for, in the last 12 months. You obviously need to take this further, they are being ridiculous.

Are you not a British passport holder @octavio1996. If you are, there is a reciprocal agreement (others have already mentioned this).

Unfortunately, it sounds as if the insurance company are trying to find any excuse not to pay. They probably do this routinely. IBS has nothing to do with your appendicitis. It's a diagnosis of exclusion anyway.