Claim resolutions and how your health insurance broker can help you

 

When you invest in a private medical insurance policy you do so to give yourself the peace of mind that you can make a claim when you need to. So what happens when your claim is declined?

At SMP Healthcare we are there to help you make sure your valid claims are not declined unnecessarily through misinformation or lack of detailed clarification from GP and specialists.

As an example this week we have assisted a client who needed to claim but when he called for pre-authorisation the claim was declined. The symptoms he had were similar to common condition that is deemed as chronic and therefore excluded from cover under the general terms of the policy yet the clients GP was fairly convinced this was not related to the condition the insurer was referring to.

Our client called up and we explained the insurance company’s reasons but confirmed that they would re-evaluate the claim if the GP would write a letter explaining why they thought these symptoms were un-related.

The letter was sent to the claims team for re-evaluation but they still declined the claim as there was insufficient detail. The client by this time was fairly despondent and getting worried. The GP was suggesting various diagnostic tests some of which would be costly. With long waiting lists on the NHS is the clients area, we suggested he pay for a private consultation and see what the specialists opinion of his condition was.

After the consultation, the client emailed us with a copy of the referral letter from the specialist who provided full, clear and unquestionable data about the clients’ condition, what tests were needed and why the symptoms did not point to chronic condition. We therefore called the insurer again and explained the scenario.

The outcome:

The claims manager re-assessed the claims declinature and reversed the decision, agreeing for all the necessary diagnostic tests. They also agreed to retrospectively pay for the initial consultation too upon receipt of the invoice from the specialist that the client had paid.

By working with us, our client has been able to ensure that his valid claim has been authorised and he has not had the hassle of dealing with the claims team as we have done this for him. For the sake of just a few phone calls, we have a happy client who is now on route to diagnosis without having to self-fund any of the treatment at all.

If you have a private medical insurance policy and would like to work with a broker who can help you every step of the way then please contact the team at SMP Healthcare and we will be happy to help you. You can call us on 01245 929129 or email enquiries@smphealthcare.com