Travel Insurance medical claim denied by AXA

goldiethedog

A few months back my son travelled to Spain and whilst there needed to seek medical assistance for tachycardia. He's never had this previously. It cost him about £400 for the medical bill.

Travel insurance was in place for the trip and there was no reason to declare any previous or current medical conditions.

The claim has been denied after AXA requested a letter from his GP to state the last 2 years medical records. The have denied the claim on the grounds that he failed to declare a visit to the GP for a strained knee ligament last year. He is on no meds or in need anything else at present. 

So my question is that are we the only people that dont comprehensively fill out all GP visits before taking out travel insurance? Have we been wasting money all these years? 

I'll post what AXA referred to in the comments

goldiethedog

Important conditions relating to health (for claims under Sections A, B, C, D, and K)

PLEASE NOTE THAT THIS POLICY DOES NOT COVER PRE-EXISTING MEDICAL CONDITIONS

This insurance is designed to cover you for unforeseen accidents and illnesses occurring during the period

of insurance. You must comply with the following conditions to make sure your cover is not affected. If you

do not comply with these conditions we may cancel the policy or refuse to deal with your claim or reduce the

amount of any claim payment.

1. At the time of taking out this policy you will not be covered for any claim arising directly or indirectly from:

a. Any medical condition you have, or have had, for which you are taking or have been taking

prescribed medication within the last 2 years.

b. Any medical condition you have, or have had, for which you are waiting to receive, or have received

diagnosis or treatment (including surgery, tests or investigations) within the last 2 years.

For your information, examples of conditions that can be indirectly linked to any medical condition

you have, or have had include:

- Someone with breathing difficulties who then suffers a chest infection of any kind.

- Someone with high blood pressure or diabetes who then has a heart attack, stroke or mini-stroke.

- Someone who has or has had cancer who suffers with a secondary cancer.

- Someone with osteoporosis who then suffers with a broken or fractured bone.

c. Any medical condition for which you have received a terminal prognosis.

d. Any medical condition you are aware of but for which you have not had a diagnosis.

e. Any medical condition for which you are on a waiting list.

f. Any medical condition for which you know you need surgery or treatment.

g. Any medical condition for which you are awaiting the results from any tests or investigations.

h. Any medical condition affecting you, that you are aware of, that could reasonably be expected to

result in a claim on this policy.

i. Any medical condition affecting a third party, that you are aware of, that could reasonably be

expected to result in a claim on this policy.

For your information, examples include but are not limited to;

- A third party who has received a terminal prognosis.

- A third party who is receiving or waiting for hospital investigation or treatment for an undiagnosed

condition or a set of symptoms.

- A third party who is receiving inpatient treatment.

- A third party who has an existing medical condition or illness, that has presented new or a change

to symptoms.

2. At any time you will not be covered for any claim arising directly or indirectly from:

a. Any medical condition you have in respect of which a medical practitioner has advised you not to

travel or would have done so had you sought his/her advice.

b. Any surgery, treatment or investigations for which you intend to travel outside of your home area

to receive (including any expenses incurred due to the discovery of other medical conditions during

and/or complications arising from these procedures).

c. Any medical condition for which you are not taking the recommended treatment or prescribed

medication as directed by a medical practitioner.

173. d. Your travel against any health requirements stipulated by the carrier, their handling agents or any

other public transport provider.

Our travel policies are offered on the understanding that you are fit to travel on the day the policy is

issued. If your health changes after the purchase of your policy and/or the date your travel tickets or

confirmation of booking were issued, you should telephone Coverwise on 01903 255 650 to discuss how

this may affect your cover.

You should also refer to What is not covered - applicable to all sections of the policy on page 19.

Annemos

I have been aware of this Travel Insurance issue for quite a while.

So I know that if I visit a doctor, however minor I would consider it to be, it will affect this part of my Travel Insurance Policy. Even a visit to the doctor regarding a cold or earache would have to be declared. (And with additional ramifications if I would have to wait for any test results!) 

Best wishes to your son. I had irregular heartbeat for some years and it was monitored every year. Then I had a pacemaker fitted and I think of it as my very best friend. 

=================================

Here is what the Insure and Go Policy Documents say:  
 

Pre-existing medical conditions

We will cover you for claims associated with those pre-existing medical conditions or disabilities you disclosed to us and we accepted in writing. We will not cover you for claims associated with pre-existing medical conditions that you did not disclose to us and we did not accept in writing. You must tell us about ALL medical conditions for which you answer yes under the Medical health disclosure requirements below.

We cannot provide cover for some conditions and not for others you choose not to include in your declaration to us.

Medical health disclosure requirements You must read the following important information:

You must disclose to us if you or anyone else insured on this policy has:

• Taken any prescribed medication or required medical treatment within the last two years;

• Been a registered in or out-patient at a hospital, clinic or GP surgery in the last two years;

• Been advised of a terminal illness. 


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And here is a reply that Staysure gives on Trustpilot reviews, when Staysure decides that they will not continue an Insurance Policy and the Policyholder has a moan. 

I am mentioning this, so that you can see how the Insurance Industry makes a link between...... what we would consider to be only minor ailments...... as something having the potential that might lead on to something more serious. 


Dear Mr R,

Thank you for your review, I am sorry that you are unhappy with us. I am sorry that we were unable to provide cover for your pre existing medical conditions.

There are times when a traveler has an undiagnosed condition, awaiting a procedure, tests or test results, no matter how minor, where our underwriters have taken the decision to exclude all pre-existing medical conditions.

This is due to the fact that they are unable to determine how the current medical circumstance with your condition is or will be affecting your other declared pre-existing conditions. It also means they are unable to determine the level of cover that would be required on your travel insurance policy in relation to this condition.

As all of these medical circumstances can affect the cover on your policy, our underwriters take an 'all in' or 'all out' approach in order to ensure that our customers fully understand what is and is not covered on their travel insurance.

We do understand it is frustrating, especially if you feel that the procedure/tests you are awaiting is a minor one. We will ensure that your feedback is passed onto the relevant team to review for future improvements.

We also hope that you will consider us for your travel insurance in the future once your medical circumstances have changed.

tacpot12

Have you complaint to AXA, and do you know you can complaint to the Insuramcen Ombudsman. 

Not visiting the Doctor when you don't need to should not result in a claim for Tachycardia investigations being turned down. It's for the Insurance company to show the relevance of the undeclared injury to the claim. The undeclared injury has to be directly or indirectly related to the claim. This seems to be complete unrelated, and it is for the Insurance COmpany to make a case for it to be otherwise.  

Annemos

I cannot find the AXA Policy wording, as they are not providing Travel Insurance any more. 

Does it say in your son's Policy Documents, that you do always have to declare trips to the Doctor within the last 2 years? 

If you cannot see that in there at all, then maybe there is a chance to fight the above link you have quoted, by saying that a strained knee ligament cannot be even indirectly linked to a case of Tachycardia. 

But if the Terms and Conditions in the actual Policy do say he should have reported it, then I suspect the Ombudsman will say that the terms and conditions were absolutely clear on the need to declare it. And he failed to do so. 

Annemos

https://www.financial-ombudsman.org.uk/consumers/complaints-can-help/insurance/pre-existing-medical-conditions

Annemos

https://www.financial-ombudsman.org.uk/decision/DRN6299563.pdf

In this case they made the Insurer work out what your son's premium would have been if he had declared the knee ligament.

Then they made them pay a proportion of the claim   what he paid / what he should have paid. 

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https://www.financial-ombudsman.org.uk/decision/DRN3422130.pdf

This case they look at how the customer answered this general question:   1) Within the last 5 years have you or anyone you wish to insure on this policy suffered any medical condition that has required prescribed medication and/or treatment including surgery, tests or investigations?...”

The Ombudsman said this was a stand-alone question. And then goes on to discuss how it might be answered and was reasonable care taken.   If, on the facts and circumstances, the Insurance Company does have grounds for saying there WAS a qualifying misrepresentation of facts. Then under the CIDRA rules, the Ombudsman says this......    but an insurer’s remedies under CIDRA apply regardless of whether there is a connection between the consumer’s medical history and the reason for their claim.

==================================


Here are the CIDRA rules........ they look at whether the way the customer responded was Deliberate/Reckless  OR Careless.  

https://www.legislation.gov.uk/ukpga/2012/6/crossheading/qualifying-misrepresentations/enacted

And here's what the Insurer is allowed to do (their allowed remedies).....

https://www.legislation.gov.uk/ukpga/2012/6/schedule/1/enacted


If it was decided the answer to the question was Careless, then there are the remedies Numbers 4 to 8.

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That's what they did in that first case above. They reworked the premiums and then paid the percentage.  And the Ombudsman also said this ........ 

For the avoidance of any doubt ERV is not entitled to rely on the pre-existing medical condition exclusion to reject Mr R’s claim. Its remedy under CIDRA is the proportionate settlement. It is not entitled to ‘contract out’ of CIDRA using any other term in its policy, which would put Mr R, the consumer, in a worse position than under CIDRA.

DullGreyGuy

This doesn't come down to policy wording but legislation known as CIDRA https://www.legislation.gov.uk/ukpga/2012/6/contents 

Effectively the law, since 2012, says that a customer on has to answer the questions asked and the questions can't be vague (eg "is there anything else you should tell us?"). However it also sets out what happens if the customer gives wrong information...

1) Intentional or Reckless - the policy can be voided, the claim can be avoided

2) Careless and wouldn't have insured if declared - the policy can be cancelled, the claim avoided

3) Careless and would have insured - policy stands, the claim is reduced by the difference in premium had it been declared

goldiethedog said:

The claim has been denied after AXA requested a letter from his GP to state the last 2 years medical records. The have denied the claim on the grounds that he failed to declare a visit to the GP for a strained knee ligament last year. He is on no meds or in need anything else at present. 

So my question is that are we the only people that dont comprehensively fill out all GP visits before taking out travel insurance? Have we been wasting money all these years? 

No you're not but you're also not the only one that has problems for not doing so. In principle yes, if you've been making false declarations for years however had you claimed for a lost suitcase they wouldn't have written to your GP and so the claim would have been paid. 


Clearly at this point Axa are thinking you intentionally or recklessly failed to declare the condition. You will need to convince them it was careless instead. 

tacpot12 said:

Not visiting the Doctor when you don't need to should not result in a claim for Tachycardia investigations being turned down. It's for the Insurance company to show the relevance of the undeclared injury to the claim. The undeclared injury has to be directly or indirectly related to the claim. This seems to be complete unrelated, and it is for the Insurance COmpany to make a case for it to be otherwise.  

No it's not @tacpot12, not since 2012. Before then absolutely the non-disclosure had to be relevant to the claim but the government changed best practice for legislation and it now fairly simple statute. 

I dont know exactly what the question that was asked is, and the Ombudsman certainly will find out, but typically its something like you must declare every condition or injury you have suffered symptom of, spoken to a medical professional with or taken medication for in the last 2 years. 

The OP now admits they had consulted a doctor, who count as a medical professional, about a condition/injury but failed to declare so. Was it careless, reckless or intentional?

"I forgot" - probably careless
"I didnt think I needed to" - youre moving towards reckless if the question is clear.

Annemos

Question for DullGreyGuy. Does the Insurer actually have to have asked the medical history question(s) in the following manner, to have done the correct procedure for CIDRA: 

1) If a customer telephones to set up a policy, then the questions must be asked by the Agent on the phone

OR

2) If the Policy is set up on line, then the questions must be asked as one goes through the set up, answering via the pop-up boxes etc etc. 


Is just mentioning the questions in the Policy Wording Booklet (Terms and Conditions of the Policy) adequate enough for CIDRA or not?      Also, do they actually have to show what questions we were asked and how we answered them on our actual Policy Schedule? (My Policy Schedule does show everything.)

Thank you. 

DullGreyGuy

No mater the channel of purchase the Ombudsman would either ask for the call transcript or the questions, including any helper text, if bought online. They will assume that you have properly read the questions including the helper text. 

There are various Ombudman cases where people have tried to argue that English isn't their first language or had no idea of the concept of, for example, "commuting" in English or their native language but the Ombudsman didnt accept it.

In some companies medical screening is done by a third party or specialist team rather than the basic sales teams but it makes no difference. 

No, the schedule doesn't have to show all questions asked and the answers. It should summarise the answers, so for example with Travel Medical you'd expect the declared conditions to be on there, with the answers to severity questions but not to show how they asked the question about declaring medical conditions. 

Policybooks shouldn't contain questions and generally are ignored for CIDRA considerations. That said, linking to the "commuting" issue above, in a case looked at recently someone tried to argue that CIDRA would apply when they claimed not to understand the question and so not declaring they were commuting was a disclosure issue but instead the insurer had stated the policy didnt over commuting so they'd have to pay the £10k or so for the third party damage and no cover for their own £8k or so damages. In this case the ombudsman decided it wasnt a CIDRA issue but the certificate clearly stated commuting wasnt covered so didnt uphold the complaint. 

Annemos

It all goes to show.

Policyholders often have a gut feeling for what they feel should be the correct/sensible way to handle a claim. 

But sometimes this is not borne out by the actual Insurance legislation. And Policyholders often have no idea of what is involved behind the scenes. 

It should be taught at school! 

I noticed on the BBC today, the famous storm issue of when is a storm not a storm... when gusts are less than 55mph. 

https://www.bbc.co.uk/news/articles/clyj6y10y15o

Ohhhh, when I looked at that this morning, the claim had been declined. Now, upon BBC intervention, the Claims Director says they ARE going to pay it.