If Your Private Medical Insurance Company Refuses To Pay Out

Aug 27, 2013 by

If Your Private Medical Insurance Company Refuses To Pay Out
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There are a lot of exclusions in Private Medical Insurance that you have to be aware of before taking it out. PMI is expensive and you want to be sure that you can use it the way it is intended to and in accordance to the policy that you have understood and agreed upon. Unfortunately, there have been a lot of complaints about insurance companies not paying for medical expenses incurred by the insured even if they were supposed to according to the terms. There are also some PMIs that do not cover the whole cost of the surgery or other treatments needed.

Some reasons your insurer may not pay out include:

Specific diseases, conditions or cause of injury – Again, the list of conditions covered by your policy is different from another. You have to make sure that before you take out a PMI, you have checked all the diseases, injury causes or conditions that you can get entitled to benefits for. Insurance companies are very strict so if they determine that your backache is caused by a condition that is not included in the coverage, you will not receive a payout for its treatment.

Condition is pre-existing – If you have a fully underwritten policy, your pre-existing conditions are not covered. If you have a moratorium, there is a set amount of time that they will not cover you for it, which usually is around 12 to 24 months. If your pre-existing condition resurfaces after the moratorium but the events that lead to that started during the moratorium, you may still not be covered. This is something that many insured think is tricky so be sure to clarify that with your insurer beforehand.

Practitioner is over charging – Your insurance company will provide you with a list of doctors and hospitals that you can use your PMI at. They do this so that the cost of doctor fees and hospital expenses do not greatly vary and are kept at mid level. If you choose a doctor that is not included in the list, they will not pay for it. If the doctor is indeed included but the fee is very high, the insurer may refuse to pay. If they decide to do but with the price they set, you will have to pay for the difference.

These are just some of the reasons your insurance company may refuse to pay for your medical care. If you think that your insurance company is being unfair and refusing to pay due to some unacceptable reasons as per your policy, review the terms and conditions carefully and talk to the insurer. If you are still unable to come to terms that are amenable for both parties and you think that you are still at a disadvantage, you can complain to the Financial Service Ombudsman so they can look into the matter and resolve it, as it should be.

Remember to discuss all details that are not clear in your policy with a financial adviser or your insurer. Also look into the fine prints of these policies so that you don’t get blind-sided when the time comes that you need the benefits.

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