What if my Medical Health Insurance Claim is Rejected?

You care about your future and that of your family. You are concerned to provide yourself and your loved ones with the best possible care should anything happen to your health. You take out medical health insurance so that if anything happens you will be in the best of hands. You feel secure as you pay your monthly premiums but then the day comes when there is a problem and you do have to make a claim. Your claim is rejected. What can you do?

Consumer rights group Which? reports that since 2005, medical health insurance claim rejections have run at about 20% per year. This is a staggering figure. Reports such as this, the ensuing media attention and the danger that the private healthcare business was falling into serious disrepute led the Association of British Insurers to create industry guidelines. Reportedly these guidelines have already had an impact. According to Nicki Kirwan, head of health and protection at the ABI "We have been taking action and the number of denied claims has been falling. We have done work on several issues, making the questions on application forms more specific, for example."

The most common reasons for rejected claims are: the discovery of something you did not disclose at the time of taking out your insurance, treatment not covered by the policy, treatment taken without prior authorisation. The policy document which you signed is a legally binding contract and lack of full knowledge of its details or deliberate non-disclosure of medical or lifestyle information are all justifiable reasons why your claim may be rejected. However the onus is also on medical insurance companies to treat consumers fairly and you do have rights if you feel you have been treated otherwise.

Your first step should be to formally complain to your insurance company. The Financial Services Authority require companies under its umbrella to have a formal and free complaints procedure. The FSA website offers free advice on how to make a complaint and is well worth a visit.

If you do not feel satisfied with the outcome of the complaints procedure you can take your complaint to the Financial Ombudsman Service (FOS). Complaints about health insurance are common for the FOS and they say on their website that 'a higher proportion of health and medical disputes require a binding ombudsman decision to resolve them than in other areas of insurance work.' There contact number and email are: 08450 801800
cmailto:complaint.info@financial-ombudsman.org.uk

As a last resort you can take the matter to court which could be a lengthy and costly exercise and particularly distressing if you are also dealing with the physical and emotional impact of illness.

Prevention is better than cure however and to avoid any future problems the following steps are vital:

-Know you policy - read the small print before you sign. Is this policy for you?
-Be very upfront and honest. Inform your insurers off your medical and lifestyle history
-Keep your insurer updated about all your medical changes and proceedures no matter how insignificant they may seem .