Health insurance will not provide cover for all treatments, medical procedures or medications. Check your policy for limitations and exclusions. When you apply for insurance, tell your insurer your whole health history to avoid issues later if you need to make a claim. Pre-existing conditions are not usually covered, unless the insurer says they are.
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Check out the Financial Services Council (FSC) FSC Code of Conduct* that has the nine standards which fall into three core objectives covering: principle ethical standards, consumer information and communication, and delivering good outcomes to consumers.
(*This is a industry code for FSC Members only (mainly made up of Life & Health Insurers, Investment Funds), and is designed to support the professionalism of the financial services industry and the FSC members. It is about increasing trust and confidence in the providers of financial services and the products they deliver.)
Get a copy of your policy and check what you are, and are not, covered for. Ask questions if you don’t understand.
Declined health insurance claims due to exclusions are a common complaint to the IFSO Schemes. Examples of health insurance exclusions might include treatment or procedures for cosmetic, dental or pregnancy-related issues; alternative or experimental treatments; and anything relating to a symptom or health issue you had before you took out the insurance (pre-existing conditions).
Pre-existing conditions are commonly defined as any condition, sign, symptom or circumstance that you know about or ought to have reasonably known about. This can be something as simple as having a sore knee or back that you may have discussed with your doctor, was not diagnosed as a medical condition. Health insurers won’t provide cover for pre-existing conditions unless they have specifically agreed to cover them.
Declined health insurance claims due to non-disclosure are a common complaint. Even if you accidentally leave out details about your medical history, your claim could be declined, and your policy treated as though it didn’t exist. If in doubt, tell your insurer everything. It can be helpful to get a copy of your medical notes you can refer to when filling out the insurance application form, or provide a copy to the insurer.
If you want to make a claim for the cost of a treatment, procedure or doctor’s visit, you will need to apply to your insurer to make sure it will pay the claim before you have the treatment, procedure or visit. This is called pre-approval.
There are all sorts of reasons that your premiums increase each year, depending on what type of policy you have. For instance, your age on a health insurance or life policy, your claims history on a vehicle policy, an increase in weather damage for your house policy. The best thing to do is talk to your insurer about why the premiums have increased. The IFSO Scheme can only consider complaints about premiums if the insurer has misrepresented the premium levels when you arranged the policy, or if the insurer has increased the premiums outside the terms of your policy.
This will be defined in the policy. There are a number of different definitions. Some policies may define a pre-existing condition as any medical condition traceable to a condition you had before taking out the policy, even if you didn’t know you had it. Others will define them as conditions you knew you had before taking out your insurance. Remember if you have an injury or sickness, or develop a condition while you have insurance cover and you subsequently change to a new company, this is likely to be treated as a pre-existing condition and won’t be covered by the new insurer.
Yes. This information helps your insurer assess your application and can affect the terms of cover it will offer you. If you leave information out, your insurer can decline to consider your claim, or make changes to you policy or even treat your policy as though it didn’t exist. If you are unsure or can’t remember your full medical history, check with your doctor, or provide a full copy of your medical history with your application.
The current law doesn’t differentiate between information that was left out deliberately or accidentally. There are still serious consequences for unintentional non-disclosure.
When you make a claim, your insurer will ask you more questions or check up on your medical history. This can lead to your insurer finding out information which it should have received when you applied for insurance.
You must give your insurer enough information to prove you have a valid claim. However, your insurer is entitled to obtain further information, which may include specialist medical reports. This can be an ongoing process, as your insurer may need information from a number of people, and they may ask you to see a doctor or specialist it appoints and you will usually have to pay for it.
It is difficult to put a time limit on how long it takes to assess a claim. Often your insurer will need more information from medical specialists, and this can take a number of months. Your insurer is entitled to fully assess the claim and can request this information, even if you do not think it is necessary.
Your insurer only has to meet its obligations under the policy. Unless your policy says the company will meet all your costs, it does not have to do so. Often your insurer will cover a proportion of the costs or will pay standard costs for a procedure.
Most life and health insurers are members of the Financial Services Council (FSC) and sign up to the FSC Code of Conduct* that has the nine standards which fall into three core objectives covering: principle ethical standards, consumer information and communication, and delivering good outcomes to consumers.
(*This is a industry code for FSC Members only (mainly made up of Life & Health Insurers, Investment Funds), and is designed to support the professionalism of the financial services industry and the FSC members. It is about increasing trust and confidence in the providers of financial services and the products they deliver.)