Making a complaint against your private medical insurer

Making a complaint against your insurer can seem daunting, not to mention stressful, but it doesn’t have to be as difficult as you think. All major private medical insurers are responsible to the Financial Services Authority (FSA) which means they are heavily regulated, ensuring your complaint will be taken seriously.

A complaint is any expression of dissatisfaction, whether justified or not. Your insurer has a responsibility to record all complaints and deal with them as efficiently as possible. Some complaints can be resolved on the day you speak to your insurer, and these are known as immediate resolution complaints. However, for some issues, such as if you’re unhappy with a denial surrounding a claim, you insurer will need to look into this in more detail, so usually an immediate resolution isn’t possible or practical.

If you’re making a complaint your insurer should treat you in a manner which is consistent with the regulations implemented by the FSA. This means:

  • You should be treated fairly. The ‘fairness principle’ is central to the way financial services in the UK are regulated. If you insurer is found to be operating practices which can be considered unfair they can receive a considerable fine.

  • You should be kept informed. Your insurer should call you back when they tell you they will, and not have an overly long and complex complaints process.

  • The complaints process should be clear and explained at the outset of your complaint. You shouldn’t be left in the dark when you’re making a complaint. It’s good customer service practice to explain what will happen and any time scales involved. At the end of the complaints process regardless of your insurers decision you should receive a written explanation.

Why complain?

Many people think the stress and hassle of making a complaint simply isn’t worth it. So what’s the point in complaining? Is it really worth the time and effort?

  • Not many people know this, but sometimes it’s financially preferable for insurers to settle your complaint rather than risking you taking it to the ombudsman. Insurers are charged £500 for every complaint the financial ombudsman service receive, regardless of fault! This can mean if your complaint is regarding a relatively small amount it could be approved, even if strictly your insurer would be well within their rights to deny it.

  • Your complaints are taken on board by the people who design the policies, so if something isn’t working and is generating lots of complaints it is more likely to be changed, creating a better service for everyone.

  • Even if your complaint isn’t upheld, you’ll be learning more about your policy and how it works, meaning you’ll be better informed for any future claims you need to make.

Main causes of complaints

  • Premium increases – Due to rising medical costs, increasing risk that comes with age, and loss of no claims discount, your premium will increase as the years go by. This can make private medical insurance unaffordable for some which generates a large body of complaints. In order to retain a degree of cover many elderly policyholders find themselves sacrificing benefits to reduce their premiums, resulting in a policy which fails to meet all their needs.

  • Denied claims – Most complaints are generated from denied claims, this can be for a variety of reasons. Some conditions which are chronic in nature fall outside the scope of medical insurance policies, cosmetic procedures are not covered and exclusions can be applied to some policies.

  • Misunderstanding the underwritingMoratorium policies in particular are highly complex and many people fail to understand the terms before taking out cover. When they come to make a claim for a pre-existing condition they are often disappointed to learn this isn’t covered, generating a large volume of complaints.

  • Specialist fees – Some specialists work outside the fee guidelines operated by your insurers. This can create problems where policyholders have to pay the shortfall on fees, and while they should be pre-warned about this it doesn’t always happen.

  • Excess – Many policyholders are unaware of how the excess works and believe it is similar to car insurance. Although it’s only payable once per policy year, the excess is payable per person and will be re-applicable in the next policy year, even if the same claim is ongoing.

The Financial Services Ombudsman

If the internal complaints process fails to provide you with a satisfactory resolution you can escalate the complaint to the Financial Services Ombudsman. The ombudsman will only investigate your complaint once you have followed your insurers internal process. They have the power to overturn your insurers decision and fine the insurer.

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