The Great 'How do insurers decide whether to pay out?' Hunt

JustJoe_2

I used to work for a claims handling company dealing with travel insurance claims.

To be honest, it's been a few years, but we used to deal with claims individually based on their merits... although mostly on how little we could get away paying.

Most people forget that there is an Excess payment to be made, so anything under that would be kicked out straight away.

Cancellation claims were mainly because of illness, most got paid but there were always a few that would be thrown out because of a pre-existing medical condition, although our definition of what constituted pre-existing could be quite loose.

Medical claims could be kicked out again if we could find it was pre-existing, or if the emergency wasn't consulted for more serious cases. Again most of these got paid.

Personal Accident claims were the danger ones, as they had a high payout, but the insurance companies would usually investigate, often looking for a get out. Usually, it was people putting themselves in unreasonable danger. I remember on poor lad had his claim rejected after he fell from his balcony, because we discovered in his medical records from the hospital abroad that he was intoxicated. His family had to pay his medical bills and the cost to have him flown back.

Baggage, Valuables & Money was were we really used to hit people hard. Firstly most basic policies have a stupidly low limit. Plus, there are also limits on individual items, usually about £200. Then most policies aren't new for old, so depreciation comes into play, and we used to generally make that up as we went along, except for cameras.

for valuables claims we often asked for stupid amounts of proof. Receipts for the items, even if they were years old, and if you couldn't provide those then maybe pictures of you with the item or insurance valuations you may have had done previously. Then there was only a limit of about £200 less an excess.

Plus we'd ask for proof of the theft for instance, such as a police report. And woe betide you if we found out you left the items unattended, your claim would be out on it's ear in a flash.

And as for Money claims, we want receipts for exchange transactions, or proof that you actually did have the money taken out of your account before you left the country. And that was limited to about £200-500 as well less an excess.

There's loads more sections of cover I could go into as well as the tricks we used to try and cut the claims down. I remember one guy I used to work with who would be really vicious and find any reason to kill a claim when he was having a bad day.

Plus, we usually ask you whether you have other insurance such as Medical or Home Insurance... the reason? So that we could attempt to recover some of our losses from your other insurers.

One thing I tell everyone now though is, that if you aren't happy, complain in writing and if it still isn't sorted then go straight to the Ombudsman.

Back when I worked in the industry, it cost the insurers a fee every time they were taken to the Ombudsman, whether they WON OR LOST. Often, they'd settle the claim once threatened with the Ombudsman, simply because it'd cost them more to fight the claim and win.

JustJoe_2

karenmc wrote: »

My brother in law went on holiday. On the plane home before take off he had a fit. He was taken to hospital in palma where he stayed mon to fri. The insurance co have refused to pay out saying its a pre existing condition,
He had 7 fits in his 20s and hasnt had one for 25 years, no medication etc.
On the questions from the co there was nothing about fits.
Can they do this? He was with his father in law , so its air fare doctors and hospital costs etc. A lot of money!
Any help would be great, the co stopped anwsering their calls whilst he was in hospital and were very rude

Unfortunately, the policy wording is King.

Most people don't understand that they have to disclose this kind of thing, because they don't read the policy properly, if at all.

I can only suggest that you get a letter from his doctor confirming that he was fit to travel at the time the policy was taken out, to the point of his fit and that the fit would have been very unlikely top occur at the time of travel and was therefore something which could not have been expected or predicted.

Write back to the insurers with this letter and ask them to review it again.

If they refuse and you exhaust all your options with the insurer then take it to the Ombudsman. Also remember that some insurers use third party companies to deal with there claims so you may want to try and contact the Insurance Company directly as this may help.

harryhound

This thread is highlighting travel insurance as a mine field.

I do understand that a contract with an insurance company is one of "utmost good faith" ie we have to answer questions the company forgets to ask (because the company is 100% on our side in any claim:rolleyes: :rolleyes: :rolleyes: :rolleyes: :rolleyes: ) HOWEVER these days insurance is bought over the internet, so there is no chance to explain something like "I've been taking an aspirin a day for 20 years" and the computer would not understand.

My lifetime claim history is car accidents in '68 & '71 and a house structure claim for a back door battered down by a burglar in '97, so I have not got a lot of experience in making claims.

My brain knows I'm still about 27, as long as I don't look in a mirror. But in reality Mrs Hound and I are "third age" material and this year we are going outside Europe for a holiday. Filled the forms in on line, data accepted.

Then Mrs Hound started fretting - about 18 months ago the family doctor called her in for a "well woman" check and said "If your blood pressure stays where it is I will have to put you on medication". Mrs Hound promptly lost a couple of stone and now has normal blood pressure BUT is she covered for dropping dead with a heart attack ?
So dodging round the 0870 number, I telephoned and found myself talking to someone who sounded pretty professional (ie not a call centre muppet reading a script). He was perfectly happy about Mrs Hound but I let slip that I had treatment from an osteopath for sciatica last autumn: "If we have to bring you back bent double in an air-ambulance, you won't be covered - you might be able to get full cover via a specialist broker". "I think I'll take the chance".

Having read this thread, I'm concerned that when Mrs Hound has her fancy new digital camera stolen, the company will refuse to pay out because "sciatica" was not on the form we completed. What do the experts on MSE think?

Harry.


"Sciatica" : a debilitating pain manifesting in the leg (ankle in my case) because the big nerve that runs down, caged within the vertebra of the backbone, is rubbing against a disc/bony nodule and getting inflamed.

ICEband_2

The mortgage insurance we have, that is supposed to cover our payments if one of us can't work through illness refused to pay up when I nearly died from multiple puminary embolisms last year. I was unable to work for six months from Feb to August, yet despite letters from my doctor, who coudn;t believe they were refusing to pay, they still declined. There resoning was that I was aware that I'd suffer from pulminary embolisms when I took out the insurance. How on earth can anyone be aware of a PE unless you've already had one?

I assume that there's nothing I can do now to make them pay up?

schoolfundraiser

misswig wrote: »

:eek:

First of all can i say how sorry i m for your loss. This is an awful time for you without having financial pressures on top of it all. I am in a very similar circumstance myself at the moment.

My ex husband died earlier on this year from lung cancer. His estate was intestate as he had not signed a will so everything was left to our DS(3) with me acting as an an administrater. Whilst we were married we took out a joint life insurance/critical illness for £72K with each other as beneficiaries. For some reason only known to him, when we split up he carried on paying the premium so i am the beneficiary of this even though we are no longer together. On top of this there is another critical illness for £82k which covers the vast proportion of the mortgage for his house (which is now my sons). As i had to apply for a letter of administrtion from the courts, i put everything into the hands of my solicitor (after 4 months i still havn't got it due to what i believe to be his incompetance-long story) so both these claims were sat on for 2 1/2 month by him with me believing he was doing something about them. When it transpired that he in actual fact he wasn't, i took over dealing with the one for £72k. after 1 1/2 months of sending off documents they asked me for medical consent to release info from his GP which i duly signed and sent back. I have now been told tht it will take 6-8 weeks for them to obtain this before they will assess the claim not only for my life insurance but also for that pertaining to the house!! Can they refuse it?? He had a crital illness refused when he was diagnosed with cancer for 33k based on not declairing a sprained wrist 11 YEARS previously. My solicitor dealing with this one but dont hold out much hope as he is a bit usless imho but if i get a new one i will be faced with a bill i cannot afford to pay at this moment in time.:eek: :eek:
Good luck

Vx

This in one of the reasons I am doing all the chasing myself - can't afford the solicitors fees but the hassle is adding to my depression and distress.

However after much chasing (approx 4 hours worth in total so far so about £8-900 in solicitors time saved) I have got them to say the money will be paid out next week (end of) and that they will pay direct into my bank account rather than send out a cheque by registered post and I then have to wait for it to clear etc. But today is the 8th of June and I contacted them to make a claim on Monday 26th March having registered his death at the last appointment on the previous Friday afternoon. I am now at the stage where they get the supervisor to ring me back to explain why it is all taking so long and to shift the blame. So far both the GP and the insurance company are blaming each other for the delay when the real cause is the need for the medical attendant's report in the first place (which they pay for).

My advice is to go to your ex-husband's doctor's surgery in person and talk to the person who deals with medical reports. They will need to get your husband's paper notes back from the health authority and it is this which takes the time. The alternative is to get the insurance company to agree to just having the info from the GP's computer system and for his GP to agree to submit the medical attendant's report on this basis. Some are happy to do it some are not. But it will still take at least 3 weeks after the insurance company get the medical attendant's report based on my experience.

In all cases after this length of time they should pay you interest on the sum insured - even if only at Bank of England rates it is the least they can do when they finally pay out - of course you pay tax on the interest so if you are a non tax payer get your form P85 in to them quickly. You also need to clarify the status of the policy payout for estate purposes to be sure it is yours not your ex-husband's estate's. As it is a joint policy it should be OK but you do need to check.

I will get to know today whether or not the solicitors lost my husband's original will when they went bust. Needless to say I will be doing the probate mostly myself and am thanking my lucky stars for all the information on the Inland Revenue website which is a goldmine.

However in your solicitor's defence there is an awful lot of work involved in probate sorting out. And it is mainly waiting for someone else to reply with information. It is actually more cost-effective for you to chase the insurance claim as your time is (relatively) free.

I will also not be leaving my will with a solicitor but registering and lodging it with the Probate Registry direct. (£15 fee)

Anyway keep your chin up and don't nag the insurance companies first thing as it will upset you for the rest of the day - leave it for the afternoon but not too late so they don't have time to deal with anything for you.

There must be light at the end of the tunnel sometime.

schoolfundraiser

From reading this thread and from my personal experience I am beginning to wonder what it is worth insuring for? Any ideas? Certainly my contents insurance is going to have a very hard scrutiny as most of my stuff is old/of sentimental value or otherwise irreplaceable.

If anything old is damaged or stolen it cannot be replaced and probably not repaired and new stuff is not the same. When we were burgled 3 years ago and I was given vouchers for the jewellery that was taken it added insult to injury as I had to buy new stuff from one accredited supplier that I didn't really like and have never worn instead of the much loved mementos from family and inherited items I had - who can replace your mother's wedding ring?

I wasn't even able to try and find something similar to the 1920s brooch my mother in law passed on to me from her mother in the antique shops and markets.

Even computers are more valuable for the information and photos you have stored on them than the hardware itself which is usually out of date and therefore worth little more than the excess. So all that is left is the TV and DVD player the CD player and perhaps personal money?

Is it worth paying out £200 a year plus an excess for those?????

Andrew24620

RibAd wrote: »

he failed to disclose a material fact. check the policy wording and terms and conditions. It doesn't matter if he didn't have a fit in 25 years, if it's on his medical record, he should have disclosed it.

I work for a the UKs largest protection privider (ie life and CIC policies. I have a reasonable knowledge on the claims side but don't profess to be an expert. This is my own opinion not the co. I work for.

For me, it's about what is reasonable. Would a reasonable person (ie a judge?!) consider an event that happened a significant time ago (e.g. over 20 years ago) should be easily recalled and disclosed. I guess the answer is it depends.

It depends on the memory of the person applying for insurance, it depends on how the question is asked.

The Financial Obmudsman Service (FOS) is known to dislike ambiguous and all-encompassing questions on life/CIC proposal forms and regularly rules against life companies where, in FOS's opinion, it was not reasonable for the proposer to recall events x years ago. For example, FOS frowns at "have you EVER had xxxx" and prefers " within the last5 years" sort of thing

The Association of British Insurers (ABI), FOS and the providers all currently studying a view that says irrespective of what was / was not disclosed of an application form is the claimable event (death or covered illness/disease) occurs after (say) three years of the policy starting then the proider cannot use non-disclosure as a reason to repudiate a claim. It'll be interesting to see how this turns out, e.g. if this comes into force I'd expect premiums to relfect the added risk and rise substantially.

If a claim is being delayed by shoddy administration/service and you're getting no joy via the usual routes, then go to provider's Group Chief Executive's office and complain. See their websites for registered addresses/ GCE name. Often this can result in more focus and effort (but not always).

My experience is that GP's, despite earning up to £70 + per report, don't provide any sort of reasonable service in getting reports done. get on tothe surgery, speak to the practice mgr, be polite but firm and keep on top of the surgery until they confirm they've sent it - it's worth the effort but appreciate it's usually the lastthing you want to do in difficult circusmstances.

Good luck all.

dunstonh

It is worth noting that only a small minority of claims are rejected. So, you have to be careful when reading threads like this not to get a distorted view of reality. A thread like this is going to attract all the potential negatives and issues.

In my professional experience, I have never had a claim from a client rejected or reduced. However, it is always important to make sure you are paying for the right insurance and you know what it does.

In the past, I have been in meetings with insurers and they have discussed claims rates and on large insurer referred to one of their life assurance plans (which was targeted towards the over S) as the liar plan due to the high rate of non-disclosure by applicants. So, the blame cannot always be passed to the insurer.

Plus, nowadays we have all these unknown trendy names introducing insurances and pricing very cheaply. Often they do it by shaving off certain bits of cover in minority claim areas or cutting back in service or having terms which can reduce claims. Many of them are selling insurance at a loss (particularly motor or household) and that is unsustainable and inevitably, that loss needs to be covered. So, you have to be really careful that you are not saving a few pennies each month at the expense of decent cover.

Joto_2

I've been reading this thread with interest and thought I'd add my own experience. We have had to make 2 claims over the last 5 years or so and each time have had to argue our corner.
I would advise from your first contact to start making a list of who you spoke to, time of call and what was agreed. I would also advise that you take out house and building insurance out together. Our first claim was a nightmare even though we were with the same company we had taken the insurance policy's out separately and had to deal with two separate claims - never again.
We have also been asked to get three quotes for works to be done and refused since we argued we would only allow one builder etc we knew to work on our property anyway and we didn't have the time or energy waiting in for tradesmen and if they wanted to compare costs they should use their own contacts to compare and if necessary to negotiate.
We have refused to buy carpets from their designated supplier and been given a cheque to use against our own choice.
Our last claim 18 months ago was for a burst pipe in the bathroom causing damage to the kitchen and breakfast room below. Only the base units were damaged because they had been standing in the water and only half the worktops were damaged. The insurance company refused to pay out for a new kitchen because 'they will only replace what is damaged and not put you in a better position than you were before'. This also applies to a three piece suite if only the chair is damaged for example.
Any way to cut a long story short we decided there was no way we could have a mismatched kitchen and it would make the house unsellable so we decided to pay out the extra for matching wall units etc.
Once the kitchen was complete I then wrote again to the insurance company again complaining about being put in this position and that the kitchen was one of the most important room of the house when you come to sell and a mismatched kitchen would and did put us in a worse condition. The insurance company did finally pay for the full kitchen so I would advise anyone to always argue if you feel you are in the right even after the event if you don't want to hold the claim up.

FlameCloud

With regards to matching items, you are not in the right to demand a new kitchen or 3 piece suite, as it is known as betterment. The insureres are supposed to offer a contribution, but this will be nowhere the full cost.

Whether they pay for all of it or not is down mainly to your financial interest in the company.