Work Health Scheme - NHS Hospital Benefit advice

superdon

Hi

In need of some advice. I pay into a work health scheme. It's not an insurance, but it offers benefits to members with decisions on claims made by its directors. It's generally to cover planned private treatment and not emergency care.

Unfortunately I recently had a problem with my appendix (very painful!) which had to be removed. There were complications and I had to have a second major op the next day, where I had some bowels removed and was on ITU for a couple of days. All pretty horrible. I was discharged after 10 days in hospital and now had a few months recovery. This all happened just a couple of weeks after my wife had our second child through c-section, so very bad timing.

I had a look through the rule booklet for the health scheme and one of the rules stated....

"In the case of emergency admissions, NHS benefit may be payable for the fourth and subsequent nights of a continuous in-patient stay directly following on from an emergency admission."

...so I thought despite the scheme stating it was not for emergency care, this rule fitted my situation. Also, the benefit is £200 per night, so would mean a claim of £1000 which is not to be sniffed at and would help with the added costs we have had and will carry on having.

I spoke to the office that looks after the scheme and they seemed to think I would be able to claim no problem but all decisions had to go through the directors of the scheme.

A couple of days later I was told my claim had been rejected. They said they sympathised with the situation, but that the NHS cash benefit was put in place for those that used NHS treatment when they could have gone private.

I am miffed about this and really cannot understand. If that's the case, why is the above rule in the rules booklet?

I can, and am going to appeal and am putting this together today. I just wondered if anyone had any thoughts or could see anything I am missing. Or any advice on what to include in the appeal.

Let me know if I need to clarify anything and thanks.

superdon

Any advice anyone?

Being a discretionary member based and "not insured" type scheme. If my appeal fails, which I think it will as they seem upset that I want to appeal, is there any independant ombudsmen or anything that I can refer the decision to?

Like I say the money would be really good at the moment, but its also the point of it now. Its upset me at a time when I should be concentrating on my recovery. I almost feel that the scheme works in a 'who you know' way, if that makes sense.

rs65

superdon wrote: »

"In the case of emergency admissions, NHS benefit may be payable for the fourth and subsequent nights of a continuous in-patient stay directly following on from an emergency admission."

The word 'may' is probably significant.

In my scheme, the cash benefit is intended for situations where you opt to go NHS. I wouldn't get anything for emergency admission.

In your case, it seems discretionary so they have exercised discretion not to pay.

Is there anything in the booklet to suggest it is actually insurance? Any reference to an insurer or FSA/FCA or FOS?

superdon

Yes, the word may is the sticking point I think. Which seems a bit loose to me. How can they justify who is deemed suitable for the benefit and who isn't when all they have is hospital discharge paperwork, which clearly explains the whole order has been and still is pretty horrific.

Its definitely not insurance, its a members discretionary scheme. So I guess that if the appeal process fails, I just accept it?