UNUM Dental Insurance accident claim refused - please help

gundo

I will try to make this saga brief. I had Unum Dental Cover through my employer (I paid £21 a month or thereabouts). At the end of March 2020 I had cycling accident which smashed 3 of my front teeth and I was rushed to hospital and kept in overnight. The following day I was seen by Maxillofacial who told that they would do their best as they weren't dentists and no dentists were working due to Covid lockdown, which had just started. The tried to remove the shattered tooth but left the root and that was it. My teeth weren't the only injuries I had, I broke my nose, my face looked like someone had attacked it with a belt sander and I also injured my neck, hands, knees and chest (the handlebar stem hit me in the sternum very hard so breathing was difficult for a few days). I also permanently damaged the sight in my left eye, but could have been much, much worse.

Anyway under my Unum policy I had £5K of accidental cover. After my accident I contacted them and explained what had happened and that I couldn't get treatment started to repair my teeth as no dentists were working. Also even when dentists started working they had a massive backlog. I was told verbally by the telephone operatives at Unum not to worry they understood the circumstances were exceptional and that the 6 month rule (you have to claim within 6 months for accidental cover) wouldn't apply.

I finally had the preliminary assessment for treatment in July 2020 and started treatment in September. I opted to have an implant to repair the damage and I understood that this wouldn't be covered by the insurance I had I hoped to get payment for the Covid PPE and the repair of the remaining teeth, which was done with resin. I was told I could claim for the work as I went along.

Things were complicated by the fact that my employer switched dental insurance provider in June 2020 from Unum to BUPA but obviously I'm claiming from Unum as I had the accident whilst insured by them. I submitted an initial claim for £2.5K for the work that I had done up to November 2020. I received £359. A month later I got an email saying that this payment was in error and that I wasn't covered and that I need to pay back the £359. I rang Unum and explained what happened (another one of several long phone calls I'd had with them since I had the accident). I told the person I spoke to, who apparently was more senior that I had been given verbal assurances by previous staff I'd spoken to that not to worry that treatment wouldn't be completed within 6 months. I was informed that they had no authority to say that and that in fact I wasn't covered as actually treatment (i.e. drilling, cutting etc) hadn't started until September (actually just with in 6 months) I wasn't covered and I had to repay what had been paid in error. Well the treatment started in July because that initial assessment cost me £145. Anyway I never paid back the £359 and I've never heard anything more. I submitted all the documentation, the treatment plan and receipts for treatment via their website as requested.

So do I just write this off? The work has been completed now (literally last month - a year of having smashed teeth) and my teeth aren't as good as before but they look OK (they're not as strong, so just for show really). I'm just over £4600 out of pocket. I don't know what to do and I feel very pessimistic about getting anywhere further with them.

Weighty1

I wouldn't just write it off as it's a significant amount of cash to be out of pocket.  I'd recommend putting in a formal complaint and then, if they don't change their decision, raise a complaint with the Financial Ombudsman Service.  The fact their staff member, who was acting on their behalf advised you that you'd be covered thus causing you to pay for the work to be done is a significant error on their part as a company.

naedanger

I too would put in a formal complaint, following through to FOS if necessary. Based on what you have said, and assuming there is not more to it, my view is you would have a good chance of success. 

Perhaps put in a Subject Access Request asking for a copy of all information they hold on you. It would be good to have evidence of the phone calls. However I suspect FOS will believe you anyway.

I think the main point is that, in the circumstances it was unfair of Unum to enforce the time limit without modifying it for the Covid circumstances. Secondly I think it was reasonable for you to rely on the information their frontline staff gave you, on a simple and topical enquiry.