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!

Of course insurance is not a loss making industry

We have this and I'm now worried too!

OP best wishes, I think you have a good case.

What are they charging? Do you know? When are they expecting payment? It’s really easy to forget things mentioned in a GP appointment when it’s just a vaguyidea and no treatment is given.

The best way to think of insurers is as a massive bunch of scamming cunts.

They take your money and will do literally ANYTHING to get out of paying out.

If you sneezed three years ago. It will be an excuse not to pay. Look at the recent case of the woman holidaying in the US whose doctors said she couldn't be moved. I think it was Aviva that said if the family did not agree at that moment on the phone to repatriate her, that they would cut funding off. They basically were willing to risk killing her to avoid paying.

I had to have emergency surgery the day I was supposed to fly on holiday. The insurer (through Lloyds) never paid out. Not pre existing conditions. The just made it impossible. They would ignore for months and then ask for another piece of info. In the end they wanted my GP to provide my entire medical history so they could examine the run up to the operation. There was no run up. At all. I gave up as it as apparent they wouldn't pay.

I lost a pair of earrings that were listed on the house insurance, the insurer said that unless I could 100 per cent guarantee they were lost on the house they wouldn't cover them.

We had our bikes stolen from our garage. They had been bought in cash, years before. We didn't have photos of them so they would pay out because there was no evidence they existed. Well apart from the fact we had been paying extra bike insurance for FIVE YEARS.

They're a bunch of cheating bastards I'm afraid.

I’m assuming you opted for private care on the understanding that you had travel insurance? The system is quite complex here with some things being covered by Medicare, others your insurance (if you have it) and often there is still a “gap payment” as I learned the hard way with my cancer treatment. If you have a breakdown of your costs you might be able to get the hospital to claim what they can from Medicare if they haven’t already done so but if you have had a private hospital bed nothing except insurance will cover that. Good luck.

It’s in the small print. You have to phone the number provided and disclose anything to them within 1-2 years and/or some permanent diagnosis. Otherwise the insurance is not valid.

You don’t just get insurance free / cheap with your bank account irrespective of any diagnoses.

When I declared my pre existing health issues to my travel insurance company (free with my bank), at the end they asked if there was anything else. I jokingly told them about a verruca. They added it to my list!

Interestingly they did cover me for my heart murmur/leaky valves.

Seriously, it must be very scary for you and I wish you the best of luck.

I forgot to add in my previous post that it is very easy to get a summary of your medical records, or at least a list of all the times you have visited your gp together with basic info from any letters they have received from consultants at hospitals. I think it was something the receptionist can do very easily.

I was asked to provide a summary of my medical records when I last renewed my Blue Badge and was pleasantly surprised that all I had to do was phone the go surgery and request one - it was emailed to me within days at no cost. Basically it is a print off listing all your gp visits with any outcomes, in my case going back to the 1980’s when I assume records were computerised, covering all my gps since then. It also included a list of my current medication.

I found this really helpful when phoning to get my recent travel insurance quote and now have a copy on my phone. No chances now of missing any vital evidence for insurance purposes!

So how do they know? If it’s self-diagnosed then you didn’t definitely have it. Stress, a change of diet or rich food can cause irritable bowels. I think you’ve got to majestic sure you five use clinical terms that can be used against you.

I’ve not RTFT, only the OP’s comments.

I was the underwriting/claims manager for an insurance company for life/health claims. I worked there for 17 years.

I didn’t have anything to do with travel insurance but the principles of underwriting and claims assessment are the same.

If your policy was fully underwritten, rather than a short-form application that just excludes pre-existing conditions, a claim can only be denied for non-disclosure if it’s a material fact.

IBS that occurred several years before and had fully resolved would not have affected the terms that were offered, nor is it related to what is being claimed. It is not a material fact and cannot be used to decline your claim.

If your policy was a short-form application and not fully underwritten, they still can’t deny your claim as a ruptured appendix is not a pre-existing condition.

You need to ask for it to be treated as a complaint and for a final response to be issued. Once you receive this you can go to the insurance ombudsman. If it gets to that point, I’d expect you to be awarded full costs, including your credit card interest, plus a distress and inconvenience sum.

Maje it clear to the insurer that you WILL be referring this to the ombudsman - each referral costs the insurer money even if they win. Knowing you won’t be backing down is sometimes enough for them to cave.

If this is the full and complete version of events as you’ve described, the insurer doesn’t stand a chance in hell of winning at the ombudsman.

I’ve heard about the reciprocal agreement, but it doesn’t seem to cover everything, and we’ve still had to pay a fortune upfront. I just don’t see how they can justify refusing to cover an emergency that has nothing to do with a minor stomach issue from half a decade ago!

Again, something is not right with this. If you were treated as a public patient, in a public hospital, which is typical for acute appendicitis, then the reciprocal agreement should cover everything you have described. It certainly did when I worked in the system, and I checked with a colleague still working and they said no changes.

I have a feeling, when you/or your DH if you were not able to interact, were asked about admission, instead of saying public, for which the reciprocal agreement should cover 100% costs associated, you said your travel insurance was paying, which then makes it a self-funded admission in the public hospital. Or, you said private on the basis you thought travel insurance would cover that (which would match with the reciprocal agreement only paying what it would have for public care). I can only conclude that’s how it’s gone this pear shaped. In which case, I can understand why your travel insurance would be scratching its head wondering why it is being asked to pay for this as self-funded or private as opposed to what should have been covered under public via reciprocal and bucking up about it.

To make it all a bit more complicated, you can choose private in a public hospital here. There is pretty much zero benefit of this to the patient apart from choice of Dr. However, given emergency admittance for an acute condition, you don’t have time/capacity to research which Dr you want, then there’s the aspect of which ones are currently on and there on site, as typically they spend a portion of time in public hospital and portion in private hospitals to make their $$. So, even if you are a private patient in public hospital you are just going to get who is on and available in theatres or ICU at the time. They will still try their best on admittance to try and get the ‘private’ ticked if they can though as the public hospitals need the extra $$ that goes with this. If you have private health coverage here it’s no loss to say yes, I always do, you just make sure they waive the private hospital excess payment you would pay in an actual private hospital. This does not extend to someone with travel insurance though who has opted to be self-funded or private via travel insurance, that’s a completely different thing!

The earrings will be because you opted not to insure them out of the house as it will have been more expensive.
If the bikes were expensive enough to insure you should have had a receipt even if you paid cash. Did you have no photos of them or anything? Just playing the devil's advocate here and looking at it from the other side

Another insurance company blag. I find that most insurance policies are guaranteed to pay out on everything - except a claim.

I haven’t RTFT so sorry if I’m repeating what’s been said. I’ve worked in the insurance industry for 15 years so just wanted to provide some insight from an insurance perspective.

You need to exhaust the insurers own complaints procedure before you can escalate to the ombudsman, get started on that asap. The insurers will be charged by the ombudsman to handle the complaint so it’s not really in their interest to let it escalate that far.

Typically with insurance they can repudiate the claim if they can demonstrate that had they been aware of whatever they allege was undisclosed they would not have provided cover. If they would have not provided cover or perhaps provided cover with some specific exclusions had you notified them of “previous IBS” then they do have grounds to dispute your claim. I’m not saying they are right, as I can’t see how the two are connected if I’m honest and it does seem a bit far fetched.

Unfortunately you might be in for bit of a battle but do not give up, press them, make sure they confirm their position in writing. Keep it all. Push for a complaint to be logged if not already and make sure they stick to the complaints time line set out.

Hope you manage to get resolved and you have a smooth recovery.

All you need is a battle when you have been so ill. ...........

I don't go abroad now because I cannot afford the insurance for my plethora of health problems. I suspect that even if I paid out for the insurance they would find a way pof wriggling out of any claim as the problems are complex.

I merely don't buy insurance as its prohibitively expensive and risk OF not being able to get a claim approved after paying ££££. It's the reason I don't got to America

I wouldn't remember every detail of every Dr appointment in my life. I don't think any insurance company has asked for that level of detail for travel?

I once forgot to declare that my smear test had picked up that I had thrush, and tried to deny me cover for a broken leg..10 years later. It was covered in the end.

No one knows if their appendix will burst. That’s one of life’s surprises. Is it bc you didn’t tell them that you were going to be out of the country. I’ve heard stories like that. Crazy.

I would challenge this on 2 grounds- 1- if it’s not been diagnosed it’s not a pre-existing condition. You can’t be expected to declare every time you have something that sends you to the GP

2- if the non-disclosure is not related to the incident, then they should not be able to avoid the policy in the entirety. Rather they can reduce the amount that they indemnify you in proportion to the increase in premium they would have charged if you had declared it. Frankly I doubt the premium would have been any different

make a formal complaint and good luck

That's just ridiculous! I would expect them to pay. I don't see how mild IBS from years ago can be linked to a burst appendix. I never knew you had to declare every single thing when applying for travel insurance, which when you reach middle age, will take a good hour or two to remember everything back to childhood. Who has time to do that? There seems little point in taking out travel insurance now. Just have to hope you don't fall ill on holiday or if you do, just expect to die in the street rather than rack up thousands of pounds for surgery. Wishing you best of luck in getting them to pay up.

Ask the insurance company for their complaint process and start a stage one complaint. If you get no luck, ask to do to a stage two complaint. Again, if no luck, go to the Financial Ombudsman.

The not declaring is usually for things they would never have offered cover for. Mild IBS isn’t something they’d never cover for. They are being unreasonable .

This is why you should check your medical records periodically to make sure that it’s accurate so that insurance companies can’t misconstrue complaints. My doctor had stated in my records that my first pregnancy was unwanted which is completely untrue it was unplanned not quite the same thing.

I agree.

On my NHS Direct App, it shows I have a medical condition of "De Quervain's Disease". I'd never even heard of it before I checked the app and certainly never been told that I had it and not receiving any form of treatment for it. Turns out it was from about 20 years ago when I had stabbing pains up both wrists and the GP referred me to a consultant - he didn't diagnose it (not to me anyway), but wanted to give me steroid injections which I refused as I didn't want to go down that route as the first level treatment, so he suggested wrist splints instead for which he wrote back to the GP to ask him to refer me to the phyisotherapy dept for wrist splints to be issued. I got them, wore them a few months, pain disappeared, splits put into the bottom drawer, forgot all about it for 20 years until I saw the "condition" on the NHS App. Eventually, after a LOT of effort and hassle, I got the GP surgery to remove it from my "list of conditions".

Another time, I looked on the app to see what the GP had noted about a consultation I'd had - it was absolutely not an accurate reflection of what I'd reported nor what the GP had responded. Things had been missed out and a couple of things that hadn't been said were included. Again, took a lot of effort, but I had the record corrected.

Makes sense to keep an eye on the NHS app to watch what they've put on and check it's accurate!

Isn’t most bank cover wanting conditions within the last year? The year starts at the renewal date. I have bank insurance that moved from Uk insurance to aviva and pretty sure both want 1 year.

Never heard of last 5 years or decades. Do you mean that because it is rolling, they are picking out from previous years what you did not declare? Even though not in current year.

If it’s not the case please tell me !!!