Travel insurance - claim rejected as not urgent

[Goldlady]

Friend of mine took out travel insurance to go skiing, specifically took out winter sports insurance. She fell on the slopes and had to be taken back by sled to the doc on site. He said injury was serious and she needed to go straight to hospital. Because she was insured she was taken to a lovely private hospital and had an operation on her knee about two hours later. Her partner then contacted the insurance company - about five hours after accident happened (t&cs say that if it is urgent they have 48 hours to contact them).

 

The insurers were initially helpful and said they would arrange special flight home. Then suddenly changed their tune, told the hospital they would not pay as the operation was not urgent, and did nothing to help her get home - she ended up being brought home by car which took over 2 days and she had to lie on the back seat the whole way home.

 

We are now fighting them as she has a bill for approx 10,000 Euros. What I cannot understand is how she was supposed to know it would not be considered urgent by the insurers' UK medical experts. You are injured and in a lot of pain and a foreign doctor tells you that you need an emergency operation. My friend is not a medical expert - what the hell was she supposed to do???

 

We have put in a complaint which will end up with the Ombudsman if they still refuse to pay - but I would welcome anyone's views or similar experiences...

 

 

Thanks

 

Goldlady (who has never been skiing and is not about to start:o)

[Bookworm]

1 - Which country?

2 - What was the exact nature of the injury?

 

Regardless of the above, if the clinic operated on her before or without the insurer's go-ahead that they would cover, that's their too-bad. the argument is between the insurers and the clinic, not her.

 

Tell her to send all correspondence to the insurers and to tell them that she expects them to handle it, and to write to the clinic telling them that all correspondence should be sent to the insurers.

 

Once you give us the info I asked for, we can look into the return to the UK part.

[Goldlady]

Bon soir Bookie, it was Austria and she had a ruptured cruciate ligament and damage to the meniscus (whatever all that is).

 

She has agreed to pay the hospital in instalments for now.

[Bookworm]

She should NOT pay them!

 

Ok, sorry, but so you can understand a bit better, we're going to have to do the science bit.

 

It is probably one of the most common skiing injuries, along with fracture of the tibial plateau.

 

What it sounds like is that the clinic jumped in and performed an operation which was not medically necessary. These 2 words are the key to the insurance company's decision: Travel insurance is not like BUPA, it covers emergency medical needs. Think of it as the A&E of medical insurance if you will.

 

So, what does it all mean? Well, it means that your friend should very definitely NOT be paying the clinic. They performed an operation they shouldn't have, now they're getting stung because they operated without the insurance's permission, well tough. Next time, they might be a bit more careful before diving in with the scalpels.

 

That's point no 1.

 

As regards the return to the UK, I assume that she came home the way she had arrived, by car?

 

You say the insurance (or more accurately the assistance company) "changed their tune", but I am going to disagree here, and this is from inside knowledge: Most people fly, and so the standard reply when notified of the injury would have been to say that they would arrange help with the flight (NOT a "special" flight, regardless of how your friend understood it, there is no way that this would have been what she was told, I promise you) when it came to returning to the uk (whether be with a new flight or additional seats to keep the leg elevated). This would then become revised when it came to return arrangements on realising that she had travelled by car originally.

 

Should she have flown home? Well, that depends: Depending on how many people were in the party, it might simply have been completely impractical; if only 2 people, for example, flying would have meant leaving the car behind, for her and companion to fly, then companion to fly back to Austria to drive back by himself once your friend was home.

Not knowing all the details is bound to leave some gaps, of course, so I can't be more specific. The problem now is that since she's home, there is little she can do to address this part apart from complaining, and whether FOS will uphold a complaint is 50/50.

 

The most important thing however is that bill, and I would strongly advise that she should not pay them and leave the insurance and clinic to battle it out.

[Goldlady]

Hi Bookie, and thanks for all of that.

 

She did fly there - her partner lives in Austria - and was supposed to be flown home on the two seats arrangement you mention - however the insurers did not get back to them and in the end her OH drove her all the way home.

 

Thanks for all the advice - I will tell her what you have suggested:)

[Bookworm]

however the insurers did not get back to them and in the end her OH drove her all the way home.

That's where they made the mistake. Your friend or her B/F should have contacted the assistance company to make sure they organised the extra seats or new flights.

 

In an ideal world, they would have done so anyway, but the stark reality is that the assistance company will be getting thousands of call a day, some life-threatening situations from all over the world, and cruciate ligaments injuries in skiing season come fast and thick, so unless someone (usually the clinic, but not always) contacts the assistance company to say they're ready to fly home, there is simply not enough hours in the day to check on every patient with an open case.

 

I'm not excusing them, you understand, merely trying to give you an idea on how it works. (Can you tell I did this for years? )

[Goldlady]

I would never have known you were a closet insurance person Bookie but you have been a tremendous help. I will tell my friend what you have suggested and let you know how we get on.

 

Thanks again

 

Goldlady

[Bookworm]

"assistance", darling, not "insurance". I could never be an insurance person, but assistance, well... There's a pattern...

[ScarletPimpernel]

Whilst I respect Bookworm's expertise in this area, I'm going to disagree with one part of her excellent post:

 

[The clinic] performed an operation they shouldn't have, now they're getting stung because they operated without the insurance's permission, well tough. Next time, they might be a bit more careful before diving in with the scalpels.

 

I'm sure that the surgeon did what he felt was in the best interest of the patient based upon his experience and clinical judgement. It would certainly be very difficult to prove otherwise. He needs the patient's consent to surgery, not the insurer's.

 

Austrian hospitals' accounts people are usually extremely efficient, and I wouldn't be at all surprised if they got a signature from the patient to confirm that she'd pay if the insurers didn't. Even if they didn't do this, they can still chase the patient; her contract with the insurers is separate to her relationship with the hospital.

 

However, Goldlady makes an excellent point:

We are now fighting them as she has a bill for approx 10,000 Euros. What I cannot understand is how she was supposed to know it would not be considered urgent by the insurers' UK medical experts. You are injured and in a lot of pain and a foreign doctor tells you that you need an emergency operation. My friend is not a medical expert - what the hell was she supposed to do???

 

I think this is key. Whilst the insured may have prejudiced the situation by failing to contact the assistance company prior to the surgery, it is not unreasonable for a patient to take the advice of a doctor experienced in treating this type of injury.

 

Most insurers define medical necessity as treatment needed to save life or limb, or that cannot reasonably wait until the insured has returned to UK. Ultimately it will come down to the clinical opinion of the treating doctor - if he felt that the surgery could not wait, I suspect the insurers would have a hard time disagreeing, especially if the assistance company didn't speak to him before making their decision.

[Goldlady]

Thanks for that SP. I am sure my friend will have signed something as you say.

 

She has now had a reply from the insurers confirming their refusal to pay. We are now left with writing to the Ombudsman.

 

I have suggested that my friend holds back from sending her first instalment to the hospital and writes to them and the insurers asking them to speak to each other. The surgeon was supposed to be sending a letter to back up her claim and she has not yet received it. I am hoping that if the hospital put the insurers under pressure it might help:(

[ScarletPimpernel]

Of course, the insurers have the benefit of hindsight.

 

If the insurers have now issued their final response, you can complain to FOS. I would be inclined to point out that the patient acted in good faith, as a layman not well versed in either general orthopaedic surgery or the niceties of knee soft tissue injuries.

 

If things had gone as they would have liked, and the assistance company had stopped the surgery, the insurer would still have had to pay for some medical expenses, and the cost of repatriation and curtailment.

 

Whilst noting what Bookworm says about insurers and assistance companies being different, in some cases they are one and the same - some insurers have in-house assistance services, and in other cases assistance companies are owned by insurers. There's no doubt in my mind that in some cases insurers have significant influence over what the assistance company provides.