Pensioner Holiday Insurance Hell

scouselad1974

Hi,
I'm just after a bit of advice regarding holiday insurance, while on holiday in spain my father had a brain hemmorage and was taken to the local private hospital, my mother produced my fathers travel insurance and treatment began, I informed my fathers insurance company and they were in touch with myself and my brother aswell as the hospital admin and doctor on a daily basis, on day 11 of my fathers treatment 2 days before he was due to be discharged the insurance company informed us that they would not be going ahead with the claim as certain pre exsisting conditions had been omitted from his health endorsement, one was that he was a smoker, although he quit over 30 years ago and the other a genuine mistake was a stroke,all other conditions had been approved and paid for, my father had even used the same company only last year and had declared a stroke so ommitting it was a genuine mistake, the insurance broker also says that because we visited their website 5 times in 1 day, due to simple mistakes as these forms are not easy to complete for a 72year old man that it looked very suspicious,anyway they told us that we where on our own and would have to pay the hospital costs of £10400 and our travel and accomadation costs, the hospital admin and doctor could not believe this as they had dealt with the insurance company for 11 days without any problem being mentioned, the doctor treating my dad also said that his condition was not caused by any pre exsisting condition and he has since advised the insurance company of this, to make matters worse my father was called directly in his hospital bed by the insurance company which could of delayed his recovery or even killed him,if the insurance company knew of these ommited conditions after receiving my dads medical history after 4 or 5 days, why did they not tell him until 11 days, if we had know they where not taking up the claim we could of moved him to an NHS hospital, we now have a £10400 spanish hospital bill and no way of paying it as my dad is a pensioner, does anybody think we have a leg to stand on if we see a solicitor ?

Ian_W

I'm no expert but hopefully the 2 points that stand out to me may be helpful and at least your post gets a "bump".
1. I don't think being a smoker 30yrs ago is strong grounds for an insurer to refuse the claim. In fact I personally [and I could be wrong!] think that's a joke!
2. The fact that the same insurer did cover your father previously even if the premium was higher might help you with this claim as it would tend to show they would have covered him even if he had declared the pre-existing condition for a higher premium - assuming of course they didn't cover him but exclude that condition.

There is a much higher duty in insurance contracts to declare things truthfully than in other contracts and insurers use this [often rightly] to deny claims. However, the Financial Ombudsman Service [FOS] has published a factsheet which you can download from THIS PAGE about medical "non-disclosure". Generally if the non-disclosure was inadvertent and the insurer would have provided cover they side with the insured.
The complaints procedure is described HERE.
Basically you have to complain to the company and exhaust their complaints system before going to the FOS. Whether you need a solicitor at this stage I doubt but you might try the CAB for some initial help if you don't feel confident in starting the complaint yourselves.
Best of Luck.

N79

I'm very sorry for the situation you and your family find themselves in and I hope your father has a speedy recovery.

Your best bet to start is not a solicitor but the Financial Services Obudsman. The Obudsman will normally find that inadvertant non-disclosure of material facts does not automatically allow the insurer to void the cover, provided that they would still have provided cover. However, each case is complex and will be looked at on its merit.

You need to raise a complaint with the insurance company, putting your case much as you do in your post. If they still refuse your claim then get a final position letter from your insurance company and complain to the Financial Obudsman Service. You can contact them for advice straight away but you will need to follow the companies complaints procedure through to their final position before the obudsman will consider your case.

You need to conduct all further contact in writing; do not phone send letters recorded delivery.

Finally, please use puctuation, sentences and paragraphs as this would make your post much easier to read!

I hope this helps

N79

scouselad1974

Hi
Thank you for your advice, I have followed the links in your reply and I am feeling slightly more positive than I did yesterday, I have today made an appointment with the Citizens Advice Bureau to discuss this matter, I am quite happy to write the letter of complaint to my fathers insurance company as I have experience of this with other companies, the only thing that worries me is the fact the the hospital in Spain will be telephoning myself on Friday to discuss the payment of my Fathers bill, as he is a pensioner he does not have £10400, In your opinion will my father still have to pay the hospital upfront and then try to reclaim this from the insurance company or is there another way around this ?

Thank you for taking the time to reply.

Ian_W

In your opinion will my father still have to pay the hospital upfront and then try to reclaim this from the insurance company or is there another way around this ?

As I said earlier I'm no expert so my opinion isn't worth "diddly" - don't know whether N79 has more idea.
Is your father still in hospital in Spain or is he back home? If he's home then it's going to be expensive for them to chase him legally for the money, though quite possible. I'd be straight with them and explain the Ombudsman situation which is probably fairly common in Europe.
TBH if the situation re the previous trip that was insured is as straightforward as it seems I think the insurers will pay up, less the additional premium they'd have charged on a formal complaint, otherwise it could take months through the FOS.

scouselad1974

hi
yes he is home now, we left Spain on Monday and the guy in charge of the hospital admin said his collegue would call me on Friday.

Sturdy

Have you looked at claiming the costs back from the European Health Insurance Card? You should have applied before you travelled, but there may be some help? https://www.ehic.org.uk/. There's also helpline details here too. As there's a healthcare reciprocal agreement in place with Spain this is a worthwhile avenue to persue.

Also, have a look at the Insurers Terms of Business Agreement, which will outline their complaints procedure, which you should comply with before you apply to the FOS to arbitrate.

N79

I don't know much about Spain but I have a feeling the EHIC card will generally not get you much and in your case I'm afraid you will get nothing as your father was treated in a private hospital. An EHIC only allows treatment in a public hospital. This is due to the fact that the EHIC allows you to be treated the same as a Spanish taxpayer and Spain, like many EU countries does not have much public healthcare. They have private healthcare with public insurance. But I am not an expert on Spain's system (OK I admit it I know virtually nothing). In Belgium all doctors and hospitals are private and even someone with full state insurance will typically have to meet 30% of hospital bills themeselves so the EHIC is about as much use as a chocolate teapot!

Normally, if the company accepted the claim they would have paid the hospital directly. However, they have rejected the claim. I'm sorry but I suspect that in legal reality, your Father needs to pay the bill and then await the outcome of the complaint. If the FOS award in your favour then they will make the insurer pay your claim plus interest plus compensation. However, if you can't pay you can't pay!

Your best bet is to inform the hospital of what is going on and maintain good communication. With luck, they will be willing to wait a bit.

If not, it will take time for the Spanish hospital to sue because of the need to change jurisdiction. If they issue in Spain then you will need to make an application to the Spanish court to change to an English (or Scottish) court. You have a right to make this application under EU Law but you will need to do it in Spanish so you will need a good local lawyer. The UK Embassy in Spain will be able to recommend someone if it comes to this. This will buy you months as the process is very slow!!!

Finally Ian W, there is indeed a Spanish version of the Ombudsman as the commission was so taken with the UK system they enforced it on the rest of Europe and made provision for cases to be passed across jurisdiction (for example if you transfer money abroad (within the EU) and something goes wrong you complain to the UK FOS and they will pass the claim on to their EU MS counterpart if necessary). It has a stupid name which I can not remember. How good other MS obudsmen are I have no idea!

I hope this helps and please note this is only my opinion and not advice.

N79