Reinstating an exclusion on Private Medical Cover

Private medical insurers are renowned for placing exclusions on a policy if the client has suffered from a medical condition within the recent past. Such was the situation with one of TMD’s Private Medical Insurance clients, who had been with Aviva for around four years, and realised that two exclusions were placed on his private medical cover every year.

One was an exclusion relating to kidney stones, which was an ongoing problem and therefore understandable. The other related to an injured left knee, which related back to a minor rugby injury some years back, for which the client had received scans but not required any treatment. He was baffled as to why this should be an ongoing exclusion and felt that his policy was not providing adequate cover in relation to the premium he was paying. As he explained: “The exclusion relates back to a minor incident. I had no treatment and there is nothing wrong with my knee. There is no reason for it to be excluded from medical cover.”

Under data protection law, brokers are not privy to the specifics of private medical insurance exclusions and do not receive a copy of the pre-authorised certificate showing exclusions, unless the client chooses to share this information. After four years of this exclusion repeatedly coming up, the client sent a copy of the latest certificate to be issued and asked TMD to investigate.

With their usual diligence and attention to detail, TMD went back to the beginning to ascertain the facts. They discovered that the pre-authorised certificates, which are provided with every private medical policy, had not been sent on by the previous private medical insurer. As a result, the exclusion had remained on the certificate and was never questioned by Aviva.

Beverley Jarvis from TMD takes up the story: “We asked Aviva to reconsider and pointed out that the pre-authorisation certificates had not been sent on by the previous insurer, which is a legal requirement. As a result, Aviva asked the client and his GP to complete relevant medical questionnaires and, once satisfied the knee injury was no longer a current condition, removed the exclusion.”

“The client was very happy with this result and felt he was now receiving fair cover for the premium he was paying. This particular story highlights TMD’s approach to helping clients and our tenacity in seeing through a situation until we arrive at a satisfactory conclusion. The role of a broker is to intercede on a client’s behalf and, using our connections and know-how, negotiate and liaise with insurers to find a successful solution.”

She cites the case of another private client who lost a watch and was finding it difficult to deal with the insurer’s continual questions and forms. “The client was busy and simply didn’t have time. We took over and in no time secured a successful resolution with an immediate pay out.

“Whether a client is looking for home, car, private medical or other insurance, that is the level of service we provide at TMD. We’ve been around for a long time and the majority of clients have been with us for many years. They know they can rely on us to provide the highest levels of personal service, whatever the requirement. Rather than an automated service, we are always here, in person, to meet their needs.”