Urgent advice - aetna international refusing cover after first agreeing

cat.hug

Hi MSE people,
wondered if anyone can give me some advice. My daughter lives outside of the UK in a British territory country. Her employer heath insurance cover is an international company with an office based in the UK. Last month, my daughter became very ill (exacerbated in part by being physically assaulted by a man on a night out). Aside from the physical injuries, she suffered emotional trauma understandably, and spiralled into a worsening state of health. I booked a flight and flew out to look after her. She was signed off sick and I was horrified when I first saw the state she was in, as she had not been able to eat, sleep, or even go out. Her employer paid for an urgent referral to a doctor who was located some 50 km away. They paid for the initial referral and I paid for the taxi transportation there and back. The doctor recommended that she be admitted as an in-patient, as a matter of urgency; to deal with the physical injuries, run some diagnostic tests and offer counselling/therapy all under 'one roof' as it were and to deal with her needs in an intensive way, rather than trying to sort things over an extended period of time and traipsing from one location to another. (Especially as she was struggling to even get out to a corner shop at this point!) The receptionist rang through to the insurance company to check she was covered. They were given the green light to begin arrangements for my daughters in-patient admittance to a private hospital and we were even assured that my own transport costs, to accompany her to hospital and be brought be home again by taxi, would be covered under the policy.
We left the doctor with a feeling of immense relief and appointment to see the doctor the following day (The doc was willing to travel to a clinic within walking distance of my daughter's home).
The following morning, we received a panicked phone call from the docs receptionist, saying that after she had sent the invoice for the scheduled care plan for my daughter, the insurers had rescinded the cover, stating she would not be covered for in-patient care. However, they gave no reason at this point as to why.
I found my daughter's insurance policy and went through the fine print with a fine-tooth comb. The only possible exclusion I could see, was that in-patient care for psychiatric/psychotherapy care was listed as'not covered'. Whilst the majority of my daughter's health decline and problems are physical in their origin, the assault in particular, did leave emotional scars, which escalated into loss of appetite, acute insomnia etc etc. She also needs to be investigated for a particular type of cancer which can manifest symptoms that appear to imitate 'mental health' problems (she has no history of mental health problems incidentally) we DO have a family history for a specific type of endocrine cancer however.
I wrote to the insurers questioning why they had agreed her hospital cover, only to rescind it the very next day. Their reply was to deny any knowledge of the phone call ever taking place between the doctors surgery and themselves. They asked me for further details of the time/location/day etc of when the phone call took place. I sent them all the details and was able to tell them the time (to within an hour) of when the doctor's receptionist spoke with the insurers office. They said to 'leave it with them, whilst they investigate.' In the meantime, my daughters health has been declining whilst we are trying to cut through all their red tape. The doctor has reiterated time and again, that my daughter needs to be in hospital. However, whist this dispute is underway, we have no way of that happening and the local hospital is not an option as it simply would not have the facilities to deal with the diagnostic side of things (local patients are usually sent back to the UK paid for by the government, if they don't have private healthcare cover). The private hospitals however, are excellent.
Another week passed before we heard from the health insurers saying they still could not find any record of the phone call and they were still investigating.
My daughter has now been off work four weeks, she is on half-pay; I have spent £300 on a one-way flight out here, but in all likelihood, will have to extend my stay another month. The upshot is that yesterday, the insurers wrote saying they still could nt find any record of that phone call, but (and here's the kicker!) Even if my daughter had been given erroneous information, they were under no obligation to pay out, if we had been informed of their mistake before any financial costs had been incurred.' They did say that they realised this must have caused some distress to myself and my daughter and were willing to (quote) offer some form of compensation (end-quote) they advised that they understood this was not the answer we wished to hear but this was their final say on the matter. They advised we if are still unhappy, we can lodge a complaint with the FOS within six months.
All in all, from my daughters first urgent appointtment and being told she needs urgent in-patient care, three weeks have passed. In which time, her employer has kindly paid ad hoc for two of the specialists consultation fees; my daughter and I have paid the other two (a sum of £300 plus 80 euros in taxis fares, plus all the costss of medications and local cab fares etc). Her employer has been understanding and more than sympathetic and they were good enough to pay out the £300 for the first two appointments. However, in all the three weeks that the insurers have procrastinated and argued, my daughter's health has not been addressed, I have written numerous emails to the insurers, pointing out that whilst I understood their exclusions and clauses, neither they, nor I were qualified physicians and could not categorically deny her cover on the assumption the causal factor was 'mental health,' Especially when a qualified physician stated categorically that she too believed the cause was physical but until my daughter is admitted and treated nothing can be confirmed nor excluded. I have spent hours, quite literallly, liaising with the insurance company, my daughters doctor, her employer and HR boss and researching the finer points of her policy etc.
I must add, the employer only opened their account with this insurance co last year and it is up for renewal this summer; the account is probably worth 100s of thousands of pounds, with a work force of over 300 plus.
Upon trying to find the insurance company's complaints procedure online, I came across a myriad of complaints about them (Aetna International) I have forwarded these links to my daughters HR Director at work as he is due to meet with the insurance rep soon. In the meantime, I have replied to the insurers 'final decision' and said I was willing to allow them chance to redress this issue, before proceding with the ombudsman complaint. I offered a solution that I felt might be beneficial to them and my daughters health care needs. Basically, my daughter is now in a situation where her sick note expires this monday. She is in no way ready to return to work, and we can only afford to pay one appointment with this doctor (150 sterling), so she is basically being forced into returning to work way before she is well enough, owing to loss of earnings and inability to pay for her health care out of her own pocket. I myself am on disability due to a previous brain aneurysm and two strokes (thankfully however, I am mobile most of the time and have the time to care for her, but unfortunately, not the money needed to pay for private doctors etc).
I have made a schedule of the costs incurred thus far, that both myself and my daughter have lost as a result of them not paying up (after initially agreeing and then rescinding). I am aware that they probably rescinded cover as it costs on average, £2,000 per night in a private hospital and the doctor recommended a week to two was needed). The insurance mentioned a willingness to offer 'some form of compensation' but did not elaborate upon how this would happen.

I suggested that they reimburse our out-going costs/losses thus far, which equates to roughly £3700 and also cover the cost for me to extend my stay to care for my daughter at home - that they cover her loss of earnings and pay for any out-patient appointments and a once a week consultation with the doctor whom she was initially referred and with whom she has built up a trust and rapport. (£600 for 4X appointments at £150) PLUS compensation for the harm and distress that their actions have caused to both myself and my child.
I have pointed out that from a financial point of view, this figure in no way represents compensatory or punitive damages, furthermore, it is a far more cost effective means of resolving this than paying for two weeks private in-patient care. I also suggested that I simply want my daughter to be able to get the medical help and care she needs, that I am willing to be here 24/7 to accompany her on appointments and for diagnostic tests, if they are unwilling to go with the doctors recommendations to have her admitted as an in-patient. (incidentallly, their cover states that the insured person will be compensated £270 per night they spend in a 'free hospital.' this alone, for three weeks would cost them £5,670) without considering costs of transportation, home care post hospital nursing etc.
Apologies for the long message, but I just want to get this sorted and we are at a pivotal point, where my daughter needs to decide whether to risk her health and return to work too soon (against her doctors orders) or risk following doctors orders and continuing sick leave on no pay, with no means of being able to pay her rent, buy food, live etc, let alone pay for further medical treatment. We have one last appointment in the morning that we have borrowed money to pay for, after which, we cant afford to pay any more. Obviously, the FOS is an option, but in the interim, we have to be realistic and need to eat. Am at my wits end and we are both exhausted. Any ideas folks? Many thanks in advance for ANY HELP/SUGGESTIONS (SORRY CAPS LOCKED) Thank you once again. Best wishes.

iammumtoone

I haven't read all the post but if your daughter is British and working for a British company, and that companies insurance cover abroad has failed their employee, have you thought to ask the employer if they would allow your daughter time to come home to be treated?

You could ask the insurance company if they would be prepared to pay for the costs to get her home to a UK hospital.

Your priority is your daughter health, you cannot force the insurance company to pay. If your daughter qualifies for 'free' treatment at home, surely the best thing to do is to try to get her home to be able to access that treatment.

rs65

Apologies but I too haven't read it all.

£300 for a one way flight home would be my choice.

takman

I did read it all! and agree with the posters above that flying her home would be the best course of action, especially if you consider that it may be something more serious than it appear.
I wouldn't keep spending money out there considering you have spent £3700 already and have got nowhere.

FutureGirl

Sounds as if insurers have issued their final response to the matter, so your next step is to go to the FOS as they have suggested, as they are not going to pay for this.

The 'compensation' they would offer would be for the distress caused. They will not compensate you of having to care for your daughter, as you were there doing that anyway. As previously mentioned if you remain unhappy - go to the FOS.

Your only options left are to continue forking out money, or bring daughter home to get treated in the UK, whichever is the most feasible for your situation. If her health is declining as you say, and you cannot afford the care, then bring her home. That is the priority here.

cat.hug

Many thanks for the replies; yes, I have looked into the possibility of having her return to the UK to get treated in the UK by the NHS. The problem with this is that she works in Gibraltar which is British territory and like many ex-pats out there, lives in Spain and travels across the border every day to work. It is a British based company and her employer provides all of their employees private health-care insurance. On the face of it, the health cover is very comprehensive and they had originally agreed for her to be treated in a private hospital in Marbella (The only hospital in Gibraltar is NHS and does not have the resources for anything 'specialist.' Most Gibraltar residents who require medical treatment that cannot be catered for in Gib, are sent to the UK (paid for by the Gb government/NHS). However, the issues my daughter is facing, is that even if she did return the UK, (which has not been home for six years) she is not guaranteed to get the medical care and diagnostic tests needed; and even if she were able to access medical care, the liklihood is that she would be put on a referral to a consultant, possibly one that would mean waiting weeks. (The NHS as you know, is already in crisis, and unlikely to look favourably upon someone arriving in the uk, purely to access the NHS; especially when they have a comprehensive private health care plan that should be covering her costs in her country of residence. Were she to take the route suggested, it would mean giving up her home and her job and the life which she has worked hard to build for herself in Spain/Gibraltar, over the past six years. The insurers are essentially reneging upon their own policy terms and conditions. I have since learned that this company has had a class action suit taken against them, by employees of Boeing who had private healthcare cover with them and suffered similar treatment.
I think the FOS is most likely the best route now in all probability? I appreciate the advice however and apologise for previous lengthy message. Many thanks for all who took the time to reply.

cat.hug

Yes, I agree that any compensation would likely be for 'distress caused.' I don't for one moment think they would compensate my time; nor do I realistically expect any consideration for that either. However, if they agreed to reimburse her loss of earnings and costs we have had already had to pay out for medical bills and medicine etc, it would at least be a start - however, I doubt very much they will if the reams of complaints about this company are any reflection of their usual (seemingly nefarious!) means of treating their customers are to be believed... doesn't look to promise that Boeing took out a class action lawsuit against them either. From what I understand of the FOS, they would at least give consideration to the time i have had to invest in dealing with this dispute, as well as consideration of any financial losses incurred and possibly compensation for distress. If the costs could at least be covered, that would enable me to pay for medical care needed in the most expedient way possible; which is the primary concern (and really, my only concern is my daughter getting back to full health)

rs65

Thy made a mistake which was corrected the next day. I can't see how they have cause the losses you speak of.