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Travel insurance refusing to pay out - advice needed please


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Two weeks before my 80 yr old mother-in-law went on holiday with a cruise line she fell and injured her leg. It wasn't a bad injury but there was bruising and bleeding. She attended her gp and the injury was dressed every few days. Two days before the holiday she asked her doctor if it was ok to go on holiday. She was told that the leg was fine and to go ahead and enjoy her holiday.

 

Unfortunately during the holiday she bumped the area again and the bleeding started up again. She sought medical help with the ship's doctor who said that it was infected and gave her antibiotics. After two days he arranged for her transfer to a privaye hospital at the next port of call in Cyprus. This of course despite the fact that her E111 card would have covered her treatment.

 

She was there for 12 days during which time she had antibiotics and intravenous drips and the wound attended to. After around a week it seemed that she was about ready to come home and it was just a matter of waiting for the insurance company to make the arrangements.

 

However two days ago the insurance company refused the claim and my mother-in-law was asked to make arrangements to pay a £12,000 bill to the hospital before she could come home! Naturally she was unable to pay and turned to me for help. After a very harrowing 24 hours with numerous phone calls to First Assist (the company given for emergency help), the cruise line, British Consul and a few others we managed to get her home with eventual help from the cruise line. Meanwhile the insurance company steadfastly refused to meet the claim as they said it was a pre-existing condition despite being asked several times to look at it again. First Assist tried hteir best to get the insurance company to meet the claim - even they said that it was a harsh decision.

 

We have argued with them that the travel insurance was taken out long before the injury and that the doctor told her she was able to travel but they still refuse to budge. Nothing would make them change their mind and they were unmoved when told they were leaving an 80yr old on her own in a Cypriot hospital with no-one to help her.

 

Naturally we want to appeal this decision. Where do we stand?

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Guest Old_andrew2018

Hi Jem16,

who are Your Mother in Laws insurers, and could up load the terms and conditions.

You should appeal against the decision, in the event of a rejection be prepared complain the FOS.

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I think that inititally this is one for the Ombudsman.

 

I don't normally recommend this route but I think that this time ths may be a safe way to go because the situation is rather obscure - to me, at any rate, and it will be interesting to see what the FOS has to say.

 

I suppose that the real question is that if she had asked the insurers before the holiday, should she go or should she ignore the doctor's clearance and cancel and claim on the insurance, what would the insurers have said? My guess, is that they would have refused to have paid out for cancellation because the doctor had cleared her to go.

However, being a normal insurer, they want it both ways and now they want to avoid a much larger bill.

 

I can see that they say that it is a pre-existing condition, but on the other hand it was cleared - and it is evident that you acted prudently, sought advice right to the last minute and very reasonably acted on the advice you ere given.

 

How much is at stake here? How much are you trying to recover?

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Guest Old_andrew2018

I agree with BankFodder I feel that you need to get a final response from the insurers, before the FOS will accept your complaint.

 

I had a problem with a claim on travel insurance, about 18 months ago, the insurers eventually paid out, just before the FOS got involved.

I made it clear that I would be escalating the complaint, and had taken time to look at published case studies.

 

Can I suggest that you look at the FOS web-page Financial Ombudsman Service use the sites search facility looking up the term Travel Insurance,and you will find these case studies, they are useful.

 

Regards

 

Andy

Edited by old_andrew2007
typo
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Hi Jem16,

who are Your Mother in Laws insurers, and could up load the terms and conditions.

 

She was insure through Co-op travel who tell me that it is Preferential Insurance company that they use.

 

My mother in law are 350 miles apart so i can't get hold of the T&C.

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I suppose that the real question is that if she had asked the insurers before the holiday, should she go or should she ignore the doctor's clearance and cancel and claim on the insurance, what would the insurers have said? My guess, is that they would have refused to have paid out for cancellation because the doctor had cleared her to go.

 

Yes I agree. She had done everything correctly as far as she thought.

 

However, being a normal insurer, they want it both ways and now they want to avoid a much larger bill.

 

Certainly looks that way.

 

How much is at stake here? How much are you trying to recover?

 

I was initially told £12,000 on Thursday night. However on Friday morning it had changed to between £8,000 and £9,000 due to the fluctuation of the Euro! At least that's what the doctor says.

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I agree with BankFodder I feel that you need to get a final response from the insurers, before the FOS will accept your complaint.

 

We certainly will do that. I have been told today that the insurers are doing a full review on the case - probably because I made such a fuss of them abandoning an 80 year old on her own and involved an MSP and a national newspaper.

 

Can I suggest that you look at the FOS web-page Financial Ombudsman Service use the sites search facility looking up the term Travel Insurance,and you will find these case studies, they are useful.

 

Thanks i will do that.

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You haven't said how much you have paid out to get her back?

You said that the orginal asking price was £12k but that you eventually managed to get her back with some help.

 

Are you trying to get the insureres to pay some costs and if so how much?

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You haven't said how much you have paid out to get her back?

 

£600 was paid to the ship's medical team. £350 was paid for a flight home as she was not able to rejoin the crusie ship and therefore missed her flight home. Both were paid by my mother in law herslef using a debit card.

 

You said that the orginal asking price was £12k but that you eventually managed to get her back with some help.

 

The hospital were insisting that my mother in law or myself pay this amount before they would release her from hospital. The cruise line eventually sent their port agent to the hospital and arranged to pay the hopsital. They have clearly stated that they intend to recover the cost from the insurer or my mother in law.

 

So at the moment my mother in law has paid £950 out of her own pocket and faces a potential bill of £12k (or whatever it ended up as)

 

Are you trying to get the insureres to pay some costs and if so how much?

 

We will be trying to get the insurers to pay the complete cost.

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Jem,

 

How long before the cruise did mum book her place? Did she buy the travel insurance at the same time as booking? Or is it it an annually renewable travel policy? Have the travel insurance company actually put the reason for the redpudiation of the claim in writing to you or mum? If so, what reason did they give and what policy term did they say that she had breached. If not, I would ask them to send you a formal letter of repudiation as a matter of urgency.

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I've looked briefly at the insurance document very kindly linked to my Helford.

If this represents the basis of the insurance taken out by you then I would say that you have a good case.

The general health requirement is that there should not be one a number of specified conditions and that if these occur even after the policy is bought you must refer back to the insurer.

This has not happened here.

The general health requirement also requires that there must not be some other significant change in your health and if there is that you must refer back. This would be the requirement which affects you. However, you took the precaution of going to the doctor and even asking the doctor if it was OK to travel. He seems to have been extremely positive about it. Because of this you very reasonably relied upon his judgment that there was not a significant change in your health.

A doctor's judgment about this has greater validity than your own. I think that the doctor's opinion, based on his treatment and familiarity with your injury and with you as a patient for two weeks is quite enough to allow you to assume very reasonably that there was not the significant change in your health which is referred to by the policy and which would then have required notification to the insurer.

 

Later on in the policy it makes it clear that there will be no cover if you travel against a doctor's advice. Clearly you have not done so.

 

Finally, the specific health requirement is that the injury in queston must not have pre-existed.

Obviously there is a question here, but according to your doctor you set off on holiday with a clean bill of health.

The injury in question was caused by a fresh impact and is arguably a new injury and not simply a continuation of an existing problem.

 

Of course it would be useful if the doctor would report that the new injury would have happened anyway - even if she had not sustained the earlier injury.

I think that you should discuss this particuar point with the doctor as soon as possible.

 

I think that you are right to involve the press. Are they following it up?

Also, you should make it clear to the insurers that if you receive any claims from anyone for the money that you will join them as co-defendants to the case and that you will do your best to get lots of publicity for it.

 

In the mean time, write formally to the insurers and tell them that you want to go to the ombudman straightaway.

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Jem,

 

How long before the cruise did mum book her place?

 

Not sure but I believe it was at least 6 weeks perhaps more.

 

Did she buy the travel insurance at the same time as booking?

 

Bought from the travel firm at the same time of booking holiday.

 

Have the travel insurance company actually put the reason for the redpudiation of the claim in writing to you or mum?

 

First Assist (emergency contact company) have told me that a letter has been sent. As my mother in law only arrived back in the UK at 1am this morning I cannot confirm this yet. Plus I live 350 miles away.

 

She has been very severely traumatised by all of this and it is very difficult to get info.

 

If so, what reason did they give and what policy term did they say that she had breached. If not, I would ask them to send you a formal letter of repudiation as a matter of urgency.

 

I have been told by First Assist that it has been rejected on the grounds of it being a pre-existing condition and that she should have informed them before travel.

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Guest Old_andrew2018

Hi

In my case we had sought advice from a general Practitioner, I think that in the case studies there a very similar problems mentioned where the Ombudsman upheld the complaint.

 

regards

 

andy

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I've looked briefly at the insurance document very kindly linked to my Helford.

 

I looked too. I need to get confirmation that this was indeed the insurers as that document does not mention First assist as the emergency contact so I am now confused.

 

 

Later on in the policy it makes it clear that there will be no cover if you travel against a doctor's advice. Clearly you have not done so.

 

Of course it would be useful if the doctor would report that the new injury would have happened anyway - even if she had not sustained the earlier injury.

I think that you should discuss this particuar point with the doctor as soon as possible.

 

I agree. We need to find out what the doctor has written on the notes especially as it was a doctor who was covering the usual doctor who was ill.

 

I think that you are right to involve the press. Are they following it up?

 

They are - the story goes in tomorrow's paper and they have been in contact with all parties. They were getting the run around from First Assist who kept saying that they were only the intermediaries and that it was the underwriters who had made the decision. I have asked repeatedly for contact details of the underwriters and they just kept saying it is us whom you phone but that the letter sent to my mother in law will contain the details of who to write to to appeal.

 

Today the newspaper phoned and told me that First Assist have now said that the matter is being put for review.

 

Also, you should make it clear to the insurers that if you receive any claims from anyone for the money that you will join them as co-defendants to the case and that you will do your best to get lots of publicity for it.

 

I have already made this clear and I have told them that I do not think they would want the story of an 80 year old widow being left to her own devices on her own in a Cypriot hospital.

 

In the mean time, write formally to the insurers and tell them that you want to go to the ombudman straightaway.

 

That will be the next step.

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Hi

In my case we had sought advice from a general Practitioner, I think that in the case studies there a very similar problems mentioned where the Ombudsman upheld the complaint.

 

regards

 

andy

 

Yes I had found one page where they did not think that a change of terms after the policy was taken out was fair or reasonable.

 

when firms vary the terms of an insurance policy - issue 36

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Interesting to note that ALL the policies are administered by UK Underwriting Limited, but the actual Insurer is AXA Insurance UK plc.

 

I have to agree with the comments made here by others that the policy terms leave something to be desired insofar as changing policy terms after a policy is incepted - Unbelievable! But then again, what do I know, only 28 years in the insurance industry, 24 years working for a Company that I couldn't possibly mention (Doh!) (And a Cruise fanatic to boot!)

 

Get that repudiation letter, formal appeal to the insurance company and get their final response letter and then a complaint to the FOS and/or a Letter Before Action and a County Court Claim? (and don't forget lots of adverse publicity)

 

H

 

H

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Interesting to note that ALL the policies are administered by UK Underwriting Limited, but the actual Insurer is AXA Insurance UK plc.

 

Not following you here. All what policies?

 

I have to agree with the comments made here by others that the policy terms leave something to be desired insofar as changing policy terms after a policy is incepted - Unbelievable! But then again, what do I know, only 28 years in the insurance industry, 24 years working for a Company that I couldn't possibly mention (Doh!) (And a Cruise fanatic to boot!)

 

I have to say this is my main issue. Why would the injury be classed as pre-existing when it wasn't there when the policy was taken out?

 

Get that repudiation letter, formal appeal to the insurance company and get their final response letter and then a complaint to the FOS and/or a Letter Before Action and a County Court Claim? (and don't forget lots of adverse publicity)

 

Will all the correspondance need to come from my mother in law? I doubt she is able to do it.

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Guest Old_andrew2018

IMHO you will be able to act for your MIL, all you need is her written consent, it will also stop her being harassed by the insurers.

 

Regards

 

Andy

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I posted the link above to the Preferential Insurance website, if you click on any of the policy document links, you will see that the actual insurance policies are administered by UK Underwriting Limited, but the actual Insurer is AXA Insurance UK plc.

 

Prefential Insurance appears to be an Underwriting Agency who are 'fronting' another insurance company's policies. Sounds strange, but surprisingly common.

 

H

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IMHO you will be able to act for your MIL, all you need is her written consent, it will also stop her being harassed by the insurers.

 

Regards

 

Andy

 

Thanks. It may be better to handle it this way as she is getting confused with all of this.

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I posted the link above to the Preferential Insurance website, if you click on any of the policy document links, you will see that the actual insurance policies are administered by UK Underwriting Limited, but the actual Insurer is AXA Insurance UK plc.

 

Prefential Insurance appears to be an Underwriting Agency who are 'fronting' another insurance company's policies. Sounds strange, but surprisingly common.

 

H

 

OK I see now.

 

I'm still trying to get to the bottom of who the actual insurer is. Preferential don't mention First Assist as their emergency contact.

 

When I was dealing with First Assist they kep telling me that they were only the intermediaries who would help in a medical emergency and that they liaise with the underwriters. However when I asked who the underwriters were they said First Assist Insurance. I asked for a telephone number to contact them and they said it was the number I was phoning.

 

I have asked my mil to get the policy which she says she doesn't have - she is staying with a friend to recover from her ordeal. I have asked the friend to go to her house with her today, find the policy, photocopy it and send me it.

 

I have checked First Assist Insurance's website but can't seem to get the policy details.

 

Unfortunately my mil seems very confused but I suppose it's no wonder after what she has been through.

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This isn't going to be an easy one to answer.

 

Your MIL had an accident before the holiday and then checked with the doctor that it was safe to travel, however whilst on holiday she has an accident that causes a pre-existing condition to flare up, OR the pre-existing condition causes further complications to the second accident.

 

I would suggest that you speak with your Dr (or other medical expert) and ascertain what contribution the pre-existing condition played in the treatment required, if they say none at all then you have a valid claim, if however they say it exasperated the treatment by xx% then the insurers would have a valid argument that they shouldn't pay that xx%.

 

I appreciate it's not going to be easy getting a Dr to guesstimate how much if any the pre-existing condition contributed to the treatment received but it would be a good starting point.

 

Mossy

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This isn't going to be an easy one to answer.

 

Your MIL had an accident before the holiday and then checked with the doctor that it was safe to travel, however whilst on holiday she has an accident that causes a pre-existing condition to flare up, OR the pre-existing condition causes further complications to the second accident.

 

No not quite. There was no pre-existing condition. It was the leg injury that happened two weeks before the holiday which flared up again after the doctor told her it was healing and to go on holiday. They called this a pre-existing condition.

 

 

Anyway as of 10 minutes ago we now have a result. Customer Relations of First Assist just phoned me to confirm that they will be meeting the claim in full! :D

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Guest Old_andrew2018

Well Jem thats great news I am really pleased, its a pity your Mother in Law had all this stress.

I do wonder how many would have given up, congratulations

 

Andy

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