Bupa problem - outpatient allowance exceeded

benjus

My wife has private medical cover through work, provided by Bupa through PMI Health Group.

She recently got 2 referrals from her NHS GP for 2 separate issues. She got appointments on the same day to see specialists at a local private hospital. One of the consultants decided that some tests were required, so these were done.

Now Bupa is refusing to cover the costs of all of these, as the outpatient allowance has been exceeded - despite having authorised all the procedures at the time.

She has obtained recordings of the phone calls (both between her and PMI, and PMI and Bupa) to authorise the procedures. It all seemed quite disconnected - there are a couple of mentions of the amount left in her outpatient allowance, and that it would be sufficient to cover the costs, but they didn't take into account the fact that other procedures had also been authorised at the same time.

They are refusing to budge on this - they are saying that it was my wife's responsibility to know how much was left in her outpatient allowance, to find out the cost of each procedure and ensure that there was enough to cover everything. Unfortunately she was under the impression that if they authorised a procedure, they were accepting liability to pay for it.

Any advice? Should she just pay up?

vaio

As always, if she feels she is being treated unfairly then complain to the insurer and refer to the FOS if still not satisfied