Mis-sold Private Medical Insurance PMI

girlingreen

Hi all,

My company offer PMI as a benefit and I opted in this year. I did so because I've been really struggling and it was suggested to me that I might have undiagnosed ADHD. I contacted the work benefits people who told me to talk directly with the PMI provider. They told me on the phone that the policy would cover diagnosis but not further appointments/prescriptions. I went ahead with the policy as the waiting list for diagnosis on the NHS where I live is actually years. My GP referred me for a diagnosis and the insurer told me to book an appointment with one of their approved providers. This took hours because you have to go through a list of hundreds of psychiatrists, manually figure out which ones offer ADHD diagnosis and then contact them all individually (a lot of them aren't accepting new patients etc). I finally found one with availability and got a provisional appointment at which point the insurer told me they didn't cover it. I cancelled the policy, got a refund and complained. They have admitted culpability and offered me £100 as a 'goodwill gesture'.

I've found the whole thing really, really upsetting. More than anything, having emotionally been picking myself and my past apart in preparation for an appointment that I then couldn't have was shattering. Part of me feels that they should have covered the cost, given that if they hadn't misled me I would've not done so much preparation work and just continued struggling through the years on the waiting list. 

Is it worth escalating my complaint or should I just take the hundred quid and move on? I think the 'gesture' is a bit insulting but I'm also really broke so I'm not sure it's worth getting myself more upset and potentially losing even that. Their letter to me is attached.

I'd really appreciate any insights. 

user1977

Are you actually out of pocket? If you've had a full refund for the policy, and didn't pay anything for the appointment, it sounds like you're £100 up?

girlingreen

user1977 said:

Are you actually out of pocket? If you've had a full refund for the policy, and didn't pay anything for the appointment, it sounds like you're £100 up?

I am, I'm just wondering if there's any way to get them to pay for what they originally told me they'd cover or not. 

user1977

girlingreen said:

user1977 said:

Are you actually out of pocket? If you've had a full refund for the policy, and didn't pay anything for the appointment, it sounds like you're £100 up?

I am, I'm just wondering if there's any way to get them to pay for what they originally told me they'd cover or not. 

No, I can't see that they'd have to do that. Would be different if e.g. you had a medical bill to pay, which you had only incurred because they had told you it would be covered.

dunstonh

 Part of me feels that they should have covered the cost, given that if they hadn't misled me I would've not done so much preparation work and just continued struggling through the years on the waiting list. 

That isn't how it works.

Is it worth escalating my complaint or should I just take the hundred quid and move on? I think the 'gesture' is a bit insulting but I'm also really broke so I'm not sure it's worth getting myself more upset and potentially losing even that. Their letter to me is attached.

You are not out of pocket. Indeed, you are £100 up.     Thats not a bad outcome.

I am, I'm just wondering if there's any way to get them to pay for what they originally told me they'd cover or not. 

No chance.

Smithcom

girlingreen said:

Hi all,

My company offer PMI as a benefit and I opted in this year. I did so because I've been really struggling and it was suggested to me that I might have undiagnosed ADHD. I contacted the work benefits people who told me to talk directly with the PMI provider. They told me on the phone that the policy would cover diagnosis but not further appointments/prescriptions. I went ahead with the policy as the waiting list for diagnosis on the NHS where I live is actually years. My GP referred me for a diagnosis and the insurer told me to book an appointment with one of their approved providers. This took hours because you have to go through a list of hundreds of psychiatrists, manually figure out which ones offer ADHD diagnosis and then contact them all individually (a lot of them aren't accepting new patients etc). I finally found one with availability and got a provisional appointment at which point the insurer told me they didn't cover it. I cancelled the policy, got a refund and complained. They have admitted culpability and offered me £100 as a 'goodwill gesture'.

I've found the whole thing really, really upsetting. More than anything, having emotionally been picking myself and my past apart in preparation for an appointment that I then couldn't have was shattering. Part of me feels that they should have covered the cost, given that if they hadn't misled me I would've not done so much preparation work and just continued struggling through the years on the waiting list. 

Is it worth escalating my complaint or should I just take the hundred quid and move on? I think the 'gesture' is a bit insulting but I'm also really broke so I'm not sure it's worth getting myself more upset and potentially losing even that. Their letter to me is attached.

I'd really appreciate any insights. 

You will need to interrogate the sales/advice process, and see who may be responsible for the incorrect advice/guidance.   

Is your employer partly to blame?    Or solely the insurer?

You cannot make the insurer pay for something that is not covered but you can seek compensation for your financial losses or emotional distress.   How you will receive will depend on the full facts of the case, but please bear in mind that any payments are compensatory, and not punitive/windfall.

girlingreen

Smithcom said:

girlingreen said:

Hi all,

My company offer PMI as a benefit and I opted in this year. I did so because I've been really struggling and it was suggested to me that I might have undiagnosed ADHD. I contacted the work benefits people who told me to talk directly with the PMI provider. They told me on the phone that the policy would cover diagnosis but not further appointments/prescriptions. I went ahead with the policy as the waiting list for diagnosis on the NHS where I live is actually years. My GP referred me for a diagnosis and the insurer told me to book an appointment with one of their approved providers. This took hours because you have to go through a list of hundreds of psychiatrists, manually figure out which ones offer ADHD diagnosis and then contact them all individually (a lot of them aren't accepting new patients etc). I finally found one with availability and got a provisional appointment at which point the insurer told me they didn't cover it. I cancelled the policy, got a refund and complained. They have admitted culpability and offered me £100 as a 'goodwill gesture'.

I've found the whole thing really, really upsetting. More than anything, having emotionally been picking myself and my past apart in preparation for an appointment that I then couldn't have was shattering. Part of me feels that they should have covered the cost, given that if they hadn't misled me I would've not done so much preparation work and just continued struggling through the years on the waiting list. 

Is it worth escalating my complaint or should I just take the hundred quid and move on? I think the 'gesture' is a bit insulting but I'm also really broke so I'm not sure it's worth getting myself more upset and potentially losing even that. Their letter to me is attached.

I'd really appreciate any insights. 

You will need to interrogate the sales/advice process, and see who may be responsible for the incorrect advice/guidance.   

Is your employer partly to blame?    Or solely the insurer?

You cannot make the insurer pay for something that is not covered but you can seek compensation for your financial losses or emotional distress.   How you will receive will depend on the full facts of the case, but please bear in mind that any payments are compensatory, and not punitive/windfall.

Thanks- I was looking at emotional distress more than anything, and also this needs to be prevented from happening again. I contacted the FOS who said it was fine to accept the company's payment before escalating the complaint so that's what I'm doing. 

dunstonh

and also this needs to be prevented from happening again. 

A complaint wont prevent that.  And the FOS have no remit on this front as they are not a regulator.

In all honesty, you are doing this to try and get more money out of them.  No point beating around the bush about it.