Seeking Advice on Private Health Insurance Claim Rejection

[Transform_IT]

Hi everyone,

I’m going through some health issues that started around May/June of this year. I visited my GP back then, who gave me a preliminary diagnosis and referred me to a specialist. I was told the wait time to see a consultant could be up to 12 months, which led me to consider using my private medical insurance through work. I signed up for this policy with WPA in April, hoping I’d never need it, but it was there as a safety net.

As my symptoms worsened, I decided to go down the private route and contacted WPA. I had a referral letter from my GP to the consultant, and I’ve since done blood tests, had consultations, and received a diagnosis. My surgery is scheduled for November 21st.

However, this Monday, I received a letter from WPA stating they won’t cover my claim, citing that my condition existed prior to taking out the policy and that I didn’t disclose this at sign-up. I checked my online documents and found an invoice for £800 for my blood tests, as well as a letter that incorrectly stated I’d experienced symptoms since last year. I called the consultant to clarify, explaining that the symptoms and GP visit were actually from May/June this year. They corrected the report and re-uploaded it to the WPA portal. When I phoned WPA to discuss this, they agreed to send it for review, but as the claim was initially denied, it’s now with the underwriters.

I’m reaching out because I’m quite anxious about the outcome. Has anyone else dealt with a similar situation? I’m concerned that, despite the corrected report, the claim may still be denied. This treatment is urgent, as my symptoms are affecting my ability to work and live a normal life. Any advice on handling this with the insurer, or insights from others who’ve gone through similar situations, would be greatly appreciated.

Thank you for any help you can offer!

 

[MrRockliffe]

If it’s with underwriters, cite treating customers fairly and the principles they must adhere to.


The mistake was made by whomever submitted the letter with incorrect information - not you. It has now been rectified, and if the only reason (as they advised) is because the symptoms were pre existing, they should now have no reason to reject it.


Good luck OP - I hope everything goes well.


When it comes to health, these situations are immensely stressful

 

[Transform_IT]

If it’s with underwriters, cite treating customers fairly and the principles they must adhere to.


The mistake was made by whomever submitted the letter with incorrect information - not you. It has now been rectified, and if the only reason (as they advised) is because the symptoms were pre existing, they should now have no reason to reject it.


Good luck OP - I hope everything goes well.


When it comes to health, these situations are immensely stressful

Thank you for the kind words. Fingers crossed.

 

[tangey]

I guess the nature of the suspicion is the small timespan between taking out the policy and the beginning of the issue (policy April, issued declared to commence in May). The letter incorrectly saying the issue started a year earlier would be bias confirmation for whoever assessed it, that the issue pre-existed the start of the policy. You don't specify, but I guess they would also consider how long you were with the employer without taking out the policy. If you were working their quite a while and then take out the policy a month before a claim, and doctor's letter said you had symptoms a year earlier, you could see why they would decline to cover.

But if the consultant corrected the bad info in writing, then odds being as the are, some people will genuinely have a condition really quite quickly after taking out a policy, so without info to the contray, you'd guess they wouldn't have grounds to decline ?

Best of luck.

 

[andybird123]

If it was rejected due to wrong info on a doctor's letter and the doctor has corrected the info then it should be un-rejected as the grounds for rejection were an error effectively. I think there's an ombudsman for complaints if they fail to do this as it sounds like you have all the correct info to support your claim. IF they still try to deny it you'll need to raise it as a formal complaint and then ask for it in writing so that you can raise it with the ombudsman, I'm pretty sure they get charged for every case that goes to ombudsman and even they will realise they'll end up paying for it anyway.

You can also get a letter from your GP confirming that you first raised this after the policy date.

 

[Transform_IT]

Thank you for your response. I'm still in the process of challenging this issue and have had to call WPA three times to explain my situation.

The condition is not pre-existing. I initially visited my GP in early July (not May, as I previously mentioned in error) due to ongoing pain. I was prescribed cocodamol and referred for an ultrasound. My last GP visit was over a year ago for an unrelated matter. Following the ultrasound, I was advised that further intervention was necessary, with an NHS waiting time of 12–18 months. Knowing I had private healthcare starting in April, I decided to use that option instead.

I’ve been with my current employer for two years. Unfortunately, I missed the window to enroll in private healthcare during my first year, but this year I signed up through the salary sacrifice scheme.

I've called WPA again this morning, and the underwriters are questioning why there is a discrepancy between the initial letter from the consultant and a revised version. The consultant clarified it was a clerical error, and I’ve explained this multiple times to the advisors on the phone, who assured me that a note had been added to my file.

My pre-op is scheduled for this Thursday, with the operation set for the following week. However, I've just received a £750 invoice due to the claim being rejected, covering the consultation and blood tests.

I’m at a loss as to what to do next. WPA doesn’t seem to be helping, and I have no other options. I’m in severe pain daily, currently off work due to this condition, and the added stress is severely affecting my mental and physical health. The thought of having to pay this bill before Christmas, on top of the uncertainty about my upcoming operation, is overwhelming.

Given the tight timeline, how would you advise I proceed since WPA is not providing the assistance I need?

 

[413x]

Thank you for your response. I'm still in the process of challenging this issue and have had to call WPA three times to explain my situation.

The condition is not pre-existing. I initially visited my GP in early July (not May, as I previously mentioned in error) due to ongoing pain. I was prescribed cocodamol and referred for an ultrasound. My last GP visit was over a year ago for an unrelated matter. Following the ultrasound, I was advised that further intervention was necessary, with an NHS waiting time of 12–18 months. Knowing I had private healthcare starting in April, I decided to use that option instead.

I’ve been with my current employer for two years. Unfortunately, I missed the window to enroll in private healthcare during my first year, but this year I signed up through the salary sacrifice scheme.

I've called WPA again this morning, and the underwriters are questioning why there is a discrepancy between the initial letter from the consultant and a revised version. The consultant clarified it was a clerical error, and I’ve explained this multiple times to the advisors on the phone, who assured me that a note had been added to my file.

My pre-op is scheduled for this Thursday, with the operation set for the following week. However, I've just received a £750 invoice due to the claim being rejected, covering the consultation and blood tests.

I’m at a loss as to what to do next. WPA doesn’t seem to be helping, and I have no other options. I’m in severe pain daily, currently off work due to this condition, and the added stress is severely affecting my mental and physical health. The thought of having to pay this bill before Christmas, on top of the uncertainty about my upcoming operation, is overwhelming.

Given the tight timeline, how would you advise I proceed since WPA is not providing the assistance I need?

Health is more important that Christmas.

I'd pay the bill and persue the claim after.
If the treatment is that important and you can afford it but it will spoil Christmas.. Christmas be damned.

 

[Transform_IT]

Health is more important that Christmas.

I'd pay the bill and persue the claim after.
If the treatment is that important and you can afford it but it will spoil Christmas.. Christmas be damned.

Sadly it's more about the fact I have two younger children who still believe in the magic of Christmas. Plus, that invoice of £750 is only for the blood test and consultation. The operation will likely be £3,500 - £7,000.

 

[413x]

Sadly it's more about the fact I have two younger children who still believe in the magic of Christmas. Plus, that invoice of £750 is only for the blood test and consultation. The operation will likely be £3,500 - £7,000.

Ah yeah that's but more expensive. I know the feeling that's what my dog has cost this year.

I guess all you can do is chase. I can't see how they can contest if the clinician has said the date was a mistake.

 

[tom_e]

Tell them you'll be contacting the financial ombudsman as your next course of action. This may be enough to light a fire under them to stop messing around.

Private medical and dental insurance

How we can help if you have a complaint about private medical insurance (including dental insurance).

www.financial-ombudsman.org.uk

 

[dlockers]