Sueing insurance company for breach of contract
Discussion
Can you sue an insurance company for breach of contract and return of premiums if they fail to provide the cover they're supposed to and in a timely manner, or am I just having a rage filled fantasy moment?
We've been paying for private health insurance, for a while. I fell and injured my hand and need a private assessment as the NHS is taking ages. That's what the private insurance is there for, isn't it? Well, maybe not so. Submitted claim, and I was told to make my appointment, anlthough I was just told to make sure that the approval was given before turned up for it. However, after a few days, I got asked for information that was basically already in the referral - reason for the referral, timeframe for the onset of symptoms and details of any related or potentially related medical history. I called them up to query these, but they said the GP referral didn't contain enough information, the physiotherapy assessment included with the letter didn't count, the GP didn't specifically say that my past medical history was not related to the injury and made a thousand excuses, so I had to go back to the GP and get another letter. So I did, and she wrote a letter specifically making sure to address the above points the health insurance company had asked about.
They didn't look at the second GP letter for ages despite promising to look at it within 3 days, and now it's the day of the appointment, nearly a month and a half after the original claim submission. I called this morning for them to hurry along, and after looking at the second letter, I got another email, this time saying that they usually require past medical history in the referral letter and could I get my GP to list this in an updated letter, and no, still not authorised.
I've called them up again and they're apparently going to look at my file again but I'm not holding my breath for today. It looks like I'm going to have to pay for the appointment and possibly any MRI scans +/- surgery if I need one myself anyway, so I'm tempted to just cancel the policy and save the money (£410 per month for a family of 4, used to be less than half that until a few months ago) for when we need any private care or switch to a different company. However, notwithstanding any of those options, given that this injury is definitely well within the criteria to be covered yet they've put up multiple unnecessary barriers and several unreasonable requests for the same information, what would be my chances of submitting an MCOL and see if I can get my premiums back as they didn't uphold their end of the contract? Is it worth a try or would I be wasting my time?
Advice on calming down as well as legal advice greatly appreciated.
We've been paying for private health insurance, for a while. I fell and injured my hand and need a private assessment as the NHS is taking ages. That's what the private insurance is there for, isn't it? Well, maybe not so. Submitted claim, and I was told to make my appointment, anlthough I was just told to make sure that the approval was given before turned up for it. However, after a few days, I got asked for information that was basically already in the referral - reason for the referral, timeframe for the onset of symptoms and details of any related or potentially related medical history. I called them up to query these, but they said the GP referral didn't contain enough information, the physiotherapy assessment included with the letter didn't count, the GP didn't specifically say that my past medical history was not related to the injury and made a thousand excuses, so I had to go back to the GP and get another letter. So I did, and she wrote a letter specifically making sure to address the above points the health insurance company had asked about.
They didn't look at the second GP letter for ages despite promising to look at it within 3 days, and now it's the day of the appointment, nearly a month and a half after the original claim submission. I called this morning for them to hurry along, and after looking at the second letter, I got another email, this time saying that they usually require past medical history in the referral letter and could I get my GP to list this in an updated letter, and no, still not authorised.
I've called them up again and they're apparently going to look at my file again but I'm not holding my breath for today. It looks like I'm going to have to pay for the appointment and possibly any MRI scans +/- surgery if I need one myself anyway, so I'm tempted to just cancel the policy and save the money (£410 per month for a family of 4, used to be less than half that until a few months ago) for when we need any private care or switch to a different company. However, notwithstanding any of those options, given that this injury is definitely well within the criteria to be covered yet they've put up multiple unnecessary barriers and several unreasonable requests for the same information, what would be my chances of submitting an MCOL and see if I can get my premiums back as they didn't uphold their end of the contract? Is it worth a try or would I be wasting my time?
Advice on calming down as well as legal advice greatly appreciated.
I'm afraid this sounds very "on brand", they have in many cases deliberately arcane systems and processes to avoid paying out and fulfilling their obligations. Follow the process, raise a complaint and when you can move to a less obviously evil coverage provider do so. Whatever process you follow will likely be quicker than the NHS route, but yes it shouldn't be this hard - but it's designed thus to make them more profitable.
I can understand the urge to take court action, but they just don't care. Hope it's not too uncomfortable in the meantime.
I can understand the urge to take court action, but they just don't care. Hope it's not too uncomfortable in the meantime.
Obviously a starting point is to compare what their terms say with what service you have received.
In reality though, it's raise a complaint and push, taking them to court is unlikely to be a productive and uplifitng exercise.
I don't know much about what's on the market but £400 pm for a family of 4 feels like it's not at the higher end of service even though it's not a trivial amount of money. But seeing if you can point to where they are being deficient against their terms is the route forward.
In reality though, it's raise a complaint and push, taking them to court is unlikely to be a productive and uplifitng exercise.
I don't know much about what's on the market but £400 pm for a family of 4 feels like it's not at the higher end of service even though it's not a trivial amount of money. But seeing if you can point to where they are being deficient against their terms is the route forward.
Possibly your “ error “ was in not following up as soon as they had the second GP letter.
Most if not all policies do say that a referral is first needed although it sounds like they were being very picky about the level of detail required.
I don’t think your premium is necessarily cheap but not do I think it expensive so assume it’s not with one of the major providers ?
Asking at this stage for your money back is also not the way to go.
I would be calling them now and saying as you have now given them all of the “ usual “ referral letters and your appointment is due you assume they are now good with you going ahead.
If they still refuse then ask to be put through to their complaints dept at the very least.
Most if not all policies do say that a referral is first needed although it sounds like they were being very picky about the level of detail required.
I don’t think your premium is necessarily cheap but not do I think it expensive so assume it’s not with one of the major providers ?
Asking at this stage for your money back is also not the way to go.
I would be calling them now and saying as you have now given them all of the “ usual “ referral letters and your appointment is due you assume they are now good with you going ahead.
If they still refuse then ask to be put through to their complaints dept at the very least.
It's with Vitality, so the third largest UK provider, and not the cheapest option, in general or theirs, either.
I did follow up after sending the second letter, and they kept saying they'd get back to me soon, but never did.
When I was talking to the second person today, she could see conversation notes from earlier phone calls, but apparently couldn't see the submitted documents with my claim so couldn't review them. She couldn't understand the difference between general past medical history and any related or relevant past medical history. The first GP letter included the list of my PMHx, and the second one confirmed that they were not related to the injury. Now they want a third listing the ones in the first again. She kept telling me I was wrong about what medical history means at which point I got rather annoyed. She might've had a chance had I not been a been doctor myself, and I hadn't said anything until then, but that really pushed me over the edge.
I'm now awaiting a call from their "dissatisfaction team", whatever the hell that is.
I did follow up after sending the second letter, and they kept saying they'd get back to me soon, but never did.
When I was talking to the second person today, she could see conversation notes from earlier phone calls, but apparently couldn't see the submitted documents with my claim so couldn't review them. She couldn't understand the difference between general past medical history and any related or relevant past medical history. The first GP letter included the list of my PMHx, and the second one confirmed that they were not related to the injury. Now they want a third listing the ones in the first again. She kept telling me I was wrong about what medical history means at which point I got rather annoyed. She might've had a chance had I not been a been doctor myself, and I hadn't said anything until then, but that really pushed me over the edge.
I'm now awaiting a call from their "dissatisfaction team", whatever the hell that is.
I’m not really sure what your previous medical history has to do with a fall unless you’ve fallen a lot previously and / or it’s a previous injury that has now been exasapated ?
Have you got a copy of the t and c of your policy ?
It sounds to me more a query about your health when you took out the policy originally rather than a query about the actual recent injury.
Hopefully the dissatisfaction team ( doesn’t sound like an actual complaints dept though ) can help you.
Have you got a copy of the t and c of your policy ?
It sounds to me more a query about your health when you took out the policy originally rather than a query about the actual recent injury.
Hopefully the dissatisfaction team ( doesn’t sound like an actual complaints dept though ) can help you.
QuickQuack said:
She kept telling me I was wrong about what medical history means at which point I got rather annoyed. She might've had a chance had I not been a been doctor myself, and I hadn't said anything until then
Isn't it nice when you can do that and simply swat someone's argument into the bin 
alscar said:
I'm not really sure what your previous medical history has to do with a fall unless you ve fallen a lot previously and / or it s a previous injury that has now been exasapated ?
Have you got a copy of the t and c of your policy ?
It sounds to me more a query about your health when you took out the policy originally rather than a query about the actual recent injury.
Hopefully the dissatisfaction team ( doesn't sound like an actual complaints dept though ) can help you.
Purely to avoid paying out money by the medical insurer. Nothing more to it than that. Have you got a copy of the t and c of your policy ?
It sounds to me more a query about your health when you took out the policy originally rather than a query about the actual recent injury.
Hopefully the dissatisfaction team ( doesn't sound like an actual complaints dept though ) can help you.
A friend ended up paying a pricy hospital bill in Switzerland last year because his travel insurer Aviva said he hadn't declared seeing his GP about a mild chest infection the year earlier (no medication prescribed). The visit to a Swiss hospital was absolutely nothing to do with his chest.
Mont Blanc said:
alscar said:
I'm not really sure what your previous medical history has to do with a fall unless you ve fallen a lot previously and / or it s a previous injury that has now been exasapated ?
Have you got a copy of the t and c of your policy ?
It sounds to me more a query about your health when you took out the policy originally rather than a query about the actual recent injury.
Hopefully the dissatisfaction team ( doesn't sound like an actual complaints dept though ) can help you.
Purely to avoid paying out money by the medical insurer. Nothing more to it than that. Have you got a copy of the t and c of your policy ?
It sounds to me more a query about your health when you took out the policy originally rather than a query about the actual recent injury.
Hopefully the dissatisfaction team ( doesn't sound like an actual complaints dept though ) can help you.
A friend ended up paying a pricy hospital bill in Switzerland last year because his travel insurer Aviva said he hadn't declared seeing his GP about a mild chest infection the year earlier (no medication prescribed). The visit to a Swiss hospital was absolutely nothing to do with his chest.
Declaring “ everything “ is always the best policy so assume OP didn’t declare something which is now being bought up.
“Forgetting “that you happened to see a GP for which nothing further was prescribed still seems a little hill to die on for the Insurer though.
Without offering an opinion on the merits of your case, as a general point you are almost certainly better off using the insurer's complaints procedure and then going to the Financial Ombudsman Service if you are not happy with the outcome, than lodging court claims. The reasons being threefold:
The ombudsman is free (to you at least)
The ombudsman has a bias towards the consumer which the courts do not - they consider overall fairness rather than just the letter of the law
An ombudsman decision is binding on the insurer but not on you, so you can still go to court if you are not happy with the outcome (whether going to court is a good idea is another question of course)
The ombudsman is free (to you at least)
The ombudsman has a bias towards the consumer which the courts do not - they consider overall fairness rather than just the letter of the law
An ombudsman decision is binding on the insurer but not on you, so you can still go to court if you are not happy with the outcome (whether going to court is a good idea is another question of course)
Mont Blanc said:
alscar said:
I'm not really sure what your previous medical history has to do with a fall unless you ve fallen a lot previously and / or it s a previous injury that has now been exasapated ?
Have you got a copy of the t and c of your policy ?
It sounds to me more a query about your health when you took out the policy originally rather than a query about the actual recent injury.
Hopefully the dissatisfaction team ( doesn't sound like an actual complaints dept though ) can help you.
Purely to avoid paying out money by the medical insurer. Nothing more to it than that. Have you got a copy of the t and c of your policy ?
It sounds to me more a query about your health when you took out the policy originally rather than a query about the actual recent injury.
Hopefully the dissatisfaction team ( doesn't sound like an actual complaints dept though ) can help you.
It's perfectly reasonable that an insurer should make checks before accepting a claim, for the benefit of honest policyholders who pay extra having disclosed previous issues, as well as the insurer. But those checks need to be done in a timely matter and processed quickly. That's what appears to be the failing here, not the asking of the questions.
Simpo Two said:
QuickQuack said:
She kept telling me I was wrong about what medical history means at which point I got rather annoyed. She might've had a chance had I not been a been doctor myself, and I hadn't said anything until then
Isn't it nice when you can do that and simply swat someone's argument into the bin 
I had to interrupt her to stop her talking rubbish at me and when she told me to let her finish, I told her that I didn't need to let her finish as it was clear that she was giving me wrong information and didn't understand the terminology correctly. alscar said:
Mont Blanc said:
alscar said:
I'm not really sure what your previous medical history has to do with a fall unless you ve fallen a lot previously and / or it s a previous injury that has now been exasapated ?
Have you got a copy of the t and c of your policy ?
It sounds to me more a query about your health when you took out the policy originally rather than a query about the actual recent injury.
Hopefully the dissatisfaction team ( doesn't sound like an actual complaints dept though ) can help you.
Purely to avoid paying out money by the medical insurer. Nothing more to it than that. Have you got a copy of the t and c of your policy ?
It sounds to me more a query about your health when you took out the policy originally rather than a query about the actual recent injury.
Hopefully the dissatisfaction team ( doesn't sound like an actual complaints dept though ) can help you.
A friend ended up paying a pricy hospital bill in Switzerland last year because his travel insurer Aviva said he hadn't declared seeing his GP about a mild chest infection the year earlier (no medication prescribed). The visit to a Swiss hospital was absolutely nothing to do with his chest.
Declaring everything is always the best policy so assume OP didn t declare something which is now being bought up.
Forgetting that you happened to see a GP for which nothing further was prescribed still seems a little hill to die on for the Insurer though.
Aretnap said:
Without offering an opinion on the merits of your case, as a general point you are almost certainly better off using the insurer's complaints procedure and then going to the Financial Ombudsman Service if you are not happy with the outcome, than lodging court claims. The reasons being threefold:
The ombudsman is free (to you at least)
The ombudsman has a bias towards the consumer which the courts do not - they consider overall fairness rather than just the letter of the law
An ombudsman decision is binding on the insurer but not on you, so you can still go to court if you are not happy with the outcome (whether going to court is a good idea is another question of course)
This is really useful, thank you very much. The ombudsman is free (to you at least)
The ombudsman has a bias towards the consumer which the courts do not - they consider overall fairness rather than just the letter of the law
An ombudsman decision is binding on the insurer but not on you, so you can still go to court if you are not happy with the outcome (whether going to court is a good idea is another question of course)
TwigtheWonderkid said:
Supposing his previous medical history included ongoing episodes of dizziness and resultant falls that had resulted in various broken bones and other injuries over many years. I think something like that not being disclosed would give them every right to avoid paying out money.
It's perfectly reasonable that an insurer should make checks before accepting a claim, for the benefit of honest policyholders who pay extra having disclosed previous issues, as well as the insurer. But those checks need to be done in a timely matter and processed quickly. That's what appears to be the failing here, not the asking of the questions.
My past medical history was on the initial GP referral (no, it doesn't include any episodes of dizziness and falls It's perfectly reasonable that an insurer should make checks before accepting a claim, for the benefit of honest policyholders who pay extra having disclosed previous issues, as well as the insurer. But those checks need to be done in a timely matter and processed quickly. That's what appears to be the failing here, not the asking of the questions.
), then they wanted the GP to state whether any of the past history was related to the fall or not, in the second letter the GP put that, and I quote, "the injury is not related to a pre-existing condition," but she didn't repeat the full past history again (well, they already have that, haven't they?). They asked the GP to comment on a very specific question in their email and she did exactly that. Then they turn round and ask for the past medical history again. I'd understand the insurance company asking for the clarification about relationship to a PMHx item if there was anything in there which could cause frequent falls, but there genuinely isn't! I fell while trying to practise a difficult figure skating turn on the ice rink, I didn't just trip over myself while shuffling along! So I guess you could say I am more prone to falling, but that's because of time spent on rather slippery ice, not because of being a doddery old bloke who can barely stand up! Sounds like a nightmare! I’ve had good experiences with AXA (lots and lots of claims) and WPA (just two claims) through work and neither of them have requested a referral letter (even though I had them from the GP) and just let me arrange consultations directly with specialists which they then pre-authorised.
Hope you get it sorted - as others said, complaints procedure is the way to go…
Chris
Hope you get it sorted - as others said, complaints procedure is the way to go…
Chris
ozzuk said:
KAgantua said:
Who is it?
I was with bupa great
Now phc not so good
Echoing BUPA, amazing service for me and my partner (company scheme) though I have noticed appointments are getting further in future - apparently due to NHS using them so much!I was with bupa great
Now phc not so good
horpe Hospital, their Consultant had a quick look-see, wrapped his hanging-out guts in clingfilm and had him transferred straight to Spire Hull (which is part of BUPA) and said Consultant took him down to theatre at 10pm that night. He had a total of five days in that hospital, his own room etc. fully funded by the NHS…
ScoobyChris said:
Sounds like a nightmare! I ve had good experiences with AXA (lots and lots of claims) and WPA (just two claims) through work and neither of them have requested a referral letter (even though I had them from the GP) and just let me arrange consultations directly with specialists which they then pre-authorised.
My experience is the same - but it sounds like it’s different if the policy is a personal one. With big corporate schemes, everything is covered anyway so there’s no scope for the insurer to be awkward - although I did have an incident with Bupa where they refused to pay a bill in full, and their employee was obnoxious about it. I just left it with HR to sort out - they probably paid it themselves.OP: How long has the policy with Vitality been running for?
My wife is insured with vitality.
In the last two years she’s claimed nearly £15k for a back operation, £4k for heart testing and drugs (found during her back pre-op) and another £2k for women’s related stuff. All via her works insurance (all be it is there top tiered policy and the company is a large multinational with thousands of employers so I imagine vitality don’t want to piss them off)
Never once has she had an issue.
Infact the only insurance company we had issue with was the post office who had our holiday travel insurance and were refusing to pay out for a £5k holiday we had to cancel because my wife couldn’t walk 5ft without being in excruciating pain from her back. That took 9 months to sort out and a letter before action.
In the last two years she’s claimed nearly £15k for a back operation, £4k for heart testing and drugs (found during her back pre-op) and another £2k for women’s related stuff. All via her works insurance (all be it is there top tiered policy and the company is a large multinational with thousands of employers so I imagine vitality don’t want to piss them off)
Never once has she had an issue.
Infact the only insurance company we had issue with was the post office who had our holiday travel insurance and were refusing to pay out for a £5k holiday we had to cancel because my wife couldn’t walk 5ft without being in excruciating pain from her back. That took 9 months to sort out and a letter before action.
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