Medical insurance - Refused claim: experimental/unproven treatment

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Based on resolver’s experience to date, it can be quite a surprise – and a stressful expense - to discover that your are not covered for any ‘unproven procedures’ you may have undergone.

Before you make a claim on your health insurance you should contact your insurer to check that you are covered as policies vary greatly in their cover and exclusions. New technology, procedures and drugs may require additional explanation or a letter from your specialist prior to the reimbursement of your claim. The fact that your insurance plan may not pay for a particular item or service does not mean that it is inappropriate for your medical care. This is determined by your specialist.

If you disagree with your insurer’s findings you should complain to the company directly. Ask for an address for customer services, and write giving clear details of your case - such as what happened, when, and why you are disputing the findings. You should include the letter from your specialist recommending this treatment for you within this formal complaint, and ask your insurer to provide a formal set of reasons as to why they are refusing to cover you for this treatment. If you are not happy with the outcome then as a last resort you can contact the Ombudsman, which will act as a mediator in your case. resolver recommends that you submit your concern in writing and resolver can assist you in submitting, recording and reminding you when and who to escalate to.

Resolver can help you resolve this issue quickly, free of charge and without the hassle. We can also help you with the next step of writing your complaint. Click on the link below to create your email.
You should know
  • If you’re making a complaint about making an insurance claim rather than a mis-sold policy, check your documents to see who the “underwriter” is. You’ll need to make a complaint to that organisation.

If you cannot resolve your issue you cannot raise your case to the Ombudsman until 8 weeks after you have first raised your complaint with your provider, or you have received a ‘letter of deadlock’ from the company stating that they cannot resolve the issue as you have asked. Your complaint must also not be older than 9 months. For an accurate decision by the Ombudsman you should provide a detailed file of your communications and supporting documentation. In addition make sure you explain what you want as an outcome as this will help assess your case.

 

 

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