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jennip37

Advice needed re group insurance complaint

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Hi all, this is a long story but hopefully someone can advise me what to do next.

 

My partner and I both have group insurance via our employers. This provides us with, amongs other things, travel insurance.

 

There are underwriters are Millstream, the brokers are Carmichael and there is also a claims settlement agency all either referred to in the correspondence between oursevles and them or in the policy booklet which makes for very confusing reading.

 

Two years ago we went on holiday and I ended up in hospital which resulted in a claim which Millstream (or whoever) settle no questions asked.

 

In May this year after boarding the plane on our outbound journey I had to get off and was taken to hospital with the exact same condition.

 

We then rebooked flights and continued on our holiday. I called our insurance company (Millstream) to check that we were covered for rebooking the flights and was told that...

 

"if the cost of cancelling the holiday would have been more that re booking flights" and "as long as the condition has been declared previously" we would be covered.

 

On our returned we did the neccessary only to be told that as I had not informed the claims settlement agency of this ongoing condition we were not covered.

 

Our argument is that they were aware due to the previous claim

 

and

 

they also state that we do not need to tell them of any conditions prior to every holiday/break etc, but only when the policy renews. But the policy has been in place since I joined the company 5 years ago and no one informs us when it is renewed.

 

I was just wondering, a side from the points above, because the policy booklet is so confusing would we have a complaint under fairness legislation?

 

I'm about to compile my complaint to all three companies involved and would like to throw something at them!!

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Without going through the entire policy wording it is difficult to know whether or not the wording could be considered to be unfair because its complexity might be confusing. Most policies have an exclusion regarding pre-existing conditions, and it is a basic tenet of insurance that the insured is under a duty to declare material fact to the insurer, and it can be argued that if the insured isn't certain as to whether or not something is material or not, they should err on the side of caution and inform the insurers anyway. However, the average person cannot be expected to know this (and so insurers end up losing Ombudsman cases), which is why so many travel insurers now make disclosure a condition of the policy.

 

If you do not automatically get a copy of the policy wording on renewal, that is a matter between you and your employer. The insurers will say that you should have asked for a copy.

 

I think the main issue here is whether the condition could be said to be pre-existing or ongoing.

 

In very broad terms - if, after the first episode, you recovered completely and have not suffered from the same condition again in the interim period, I think the insurers will struggle to avoid settling by claiming that it is an ongoing condition. If, on the other hand, the condition has been diagnosed and you have been receiving regular treatment for it, they may have a case.

 

In terms of complaining, there will be information on the policy wording that outlines the compliant procedure. Follow it, because if the answers are unsatisfactory you can go to the Financial Ombudsman Service; if you have not followed the complaint procedure they won't deal with the case.

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Thanks. That's very helpful as I suffer from this condition at random times but on average once every two years for no apparent reason and I do not take any medication etc for it. Will keep battling on!!

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