Health insurer declined treatment. Any guidance?

  • 2 replies
  • 10 subscribers
  • 462 views

Hi there,

I was diagnosed with endometrial cancer. Most people who get endometrial cancer are post-menopausal and the standard treatment is a total hysterectomy. However, I’m in my 30s, and meet the criteria for ‘fertility-preserving treatment’ involving hormonal therapy and regular biopsies to monitor for any sign of recurrence until I have a child (after which, I will have a hysterectomy).

I am covered by private health insurance. However, when I asked them to approve my hysteroscopy procedure for the purposes of a) cancer-monitoring biopsies and b) inserting the IUD (hormone treatment), they declined the whole procedure because of the IUD.

Their reasoning was:
- they don’t cover fertility treatment (this procedure is definitely not fertility treatment)
- they consider the IUD to be a standard procedure that a GP can do
- they don’t cover the procedure because it’s ‘unconventional treatment’ for endometrial cancer - they will only cover a total hysterectomy

Frustratingly, they’ve told me that they would have no problems covering this exact procedure with the IUD if it was for the purposes of treating endometriosis or heavy periods.

(There is something so wrong about an insurance company pushing paying patients out onto an already overwhelmed NHS system to boost their profit margins.)  

I have two questions:

- Is it possible for me to pay for part of my treatment and have the health insurer pay for the part that they definitely do cover? If I was only getting the hysteroscopy for the purposes of biopsies alone I would be covered. Can I pay for the IUD separately even though it would happen in the same procedure?

- Do I have any other options/rights here? They consistently misquoted my policy and my oncologist’s report in their reasoning to decline treatment so I really have trouble believing them when they say they have grounds to decline my procedure.

  • Hello  ,
     
    Thanks for getting in touch. I’m sorry to hear about the issues you’re having with your medical insurance.  
     
    With these types of policies, the wording in the terms and conditions can vary with different providers. You should be able to request a copy of the terms and conditions from the provider so you can review exactly how the policy works and whether it would be possible to partially claim on the insurance and pay the rest yourself. You could also contact the insurer and ask them if this is possible.  

    We could also have a look at the policy terms and conditions and if you’d like our assistance with this please get in touch on 0808 808 0000 and select option 1, then 2 and then 1 again to get through to our financial guidance team, we are open between 8am and 6pm Monday to Friday.  

    For your second question, you do have the right to have this treated as a complaint. All insurers have a complaints procedure. Once you’ve contacted them, they’ll explain what happens next.  
     

    Sending the complaint in writing 

    Write ‘complaint’ at the top of the letter/email. 

    Include details of the policy holder’s name and policy reference number. 

    Try to be brief and to the point. Set out the facts clearly and in a logical order. It may also help to include a timeline of events. 

    Explain what the problem is and what the insurer could do to resolve the complaint. 

    Include copies of any paperwork which may help the complaint. 

    Always make a copy of any letters or paperwork sent to the company - it might be needed later. 


    Complaining over the telephone 

    If you prefer, it’s also possible to make a complaint over the phone. 

    Ask for the name and job title of the person who takes the call and make a note of the date and time of all calls. 

    Write down details of the conversation for future reference. 

    It always helps to remain calm, however difficult this maybe. Staying calm helps to get your side of the story across more clearly.  

    Again, try to be brief and to the point. Setting out the facts clearly and in a logical order 


    Other things to think about 

    Make the insurer aware of any disability (including a cancer diagnosis) or difficulties in communicating verbally or in writing.  

    Don’t expect an immediate response, it may take the company some time for them to look into the complaint and respond. But look out for an acknowledgement, this means that the company has received the complaint and are looking into it. 

    What Happens next? 

    Insurers usually have 8 weeks to investigate a complaint.  


    Financial Ombudsman Service (FOS) 

    If the company hasn’t looked into and responded to the complaint after 8 weeks, or if you’re not happy with their response, the next stage is to complain to the Financial Ombudsman Service (FOS). The FOS is there to give an unbiased answer about what’s happened. If they decide someone’s been treated unfairly they have legal powers to put things right. 

    In order to look at the complaint, the FOS will need the policy number, a brief outline of the problem, and copies of any paperwork or letters. 

    The FOS will look at both sides of the story and find out the facts of what’s happened. If their decision is in favour of the person complaining, they will tell the insurer to put the matter right and may ask them to pay compensation and costs. 

    For information on how to send a complaint to the FOS visit: 

    www.financial-ombudsman.org.uk/consumer/complaints.htm 

    For information on the type of complaint the FOS deal with visit: 

    www.financial-ombudsman.org.uk/about/index.html 

     

    Time limits to consider 

    It’s important to ask the FOS to look at a complaint decision as soon as possible after the company have responded. This is because there are set time limits, after which they would need the company to agree to them looking at a complaint after a certain amount of time has passed. 

    The limits are: 

    • 6 months from the company’s final response to the complaint. 
    • 6 years from the event the individual is complaining about. Or (if later) 3 years from when they knew, or could reasonably have known, they had a reason to complain. 

     

    For further information on these time limits visit: 

    https://www.financial-ombudsman.org.uk/faqs/all/time-limits-consumers-making-complaint-complaint-time 

     

    For further information, contact the FOS directly: 

    Telephone: 0800 023 4567 (freephone) 
     

    Or visit: http://www.financial-ombudsman.org.uk/contact/index.html 

     
    Again though, if you would like us to review the policy first and there are grounds to complain we can also assist with this.  

    I hope this provides you with a bit of helpful information. If you have any further questions or would like to discuss things such as mortgages or pensions, then please don’t hesitate to get back in touch. 

    Yours Sincerely, 

     

    Chris H 
    Financial Guide 

     

     

     

    The Financial Guidance Service will not advise you on the merits of buying, selling, cancelling or making a claim on a specific financial product from any company or otherwise provide you with any regulated services. As a guidance service, we do not provide financial advice or carry on other activities that are regulated and we are not authorised or regulated by the Financial Conduct Authority. No part of our service constitutes, nor is intended to constitute, a financial promotion within the meaning of the Financial Services and Markets Act 2000 nor an invitation or inducement to engage in investment activity. 

     

    The aim of the Financial Guidance Service is to provide you with information to help you make informed decisions about your personal finances. For financial advice, including recommendations to buy, sell, cancel or make a claim on specific financial products or to obtain any other type of financial services, you should speak to a financial adviser or company who is permitted to provide you with those services. You can find a local financial advice firm or other type of firm who provides regulated services on the Financial Conduct Authority's website - https://register.fca.org.uk/directory/s/. 

     

    The information that we provide you is for general guidance on your rights and responsibilities and is not legal advice. We are not liable to you for any information or services obtained by you from, or given to you by, a third party. 

     

  • Thanks so much Chris, this is incredibly helpful. I’ll give the team a call. Cheers.