Retrospective change to ins exclusion in order to refuse claim

[derynw]

Anyone ever had their insurance co change an exclusion retrospectively so that they can now refuse claim right out.
Insured with reputable (so I thought) company and have had a few claims that were treated ok. Claimed two years ago for fracture and given the usual exclusion on renewal though they wanted to exclude the whole skull. I questioned exclusion and got it reduced to excluding fracture on basis of report from vet. Now have claim in for other problem with head and they are refusing to pay on basis new problem is in same area as old fracture. But to add insult to injury they are saying that if vet had reported that there was still small lump where fracture was they wouldn't have changed the exclusion to be just fracture so they now say changing exclusion back to whole skull effective from 2012 renewal date. So won't accept claim on that basis either.
This only came up after I had lodged complaint.

Am I being paranoid but does this hint of sour grapes to you and is it just a desperate measure on their side as believe that there original reason for declining was not very strong.

Will never take out horse ins again going to start savings account when I have money to spare. None spare at moment as having to pay vet bill in instalments just in case.

Now composing letter for next stage of complaints procedure and determined to take to ombudsman if necessary

 

[ihatework]

What is the new injury to the skull?

 

[elijahasgal]

I am 99% certain that any bone healing would leave a lump, so that you have a good reason to be unhappy.
I would get your vet to write a report that the bone lump would be considered perfectly normal after the previous injury, and any fracture healing, and that the present claim is highly unlikly to be caused by previous injury/accident and therefore is a totally seperate issue x

 

[derynw]

Yes done all that but they are still sticking to its in the same place so must be linked. New problem isn't injury it's very rare cancer of the cartilage - chrondrosarcoma, if you google it for horses you can't get any info. Own vet never seen it before in 25 years or practice.

Most annoying element is retrospective change just wonder if happened to anyone else.

 

[cobgoblin]

Take it to the insurance ombudsman. Just google for contact details.

 

[derynw]

Will do cobgoblin but have to go through full complaints procedure first otherwise ombudsman will just send it back. Intend to see it through to end just time frame is so longer ombudsman can take months to review cases.

 

[Polos Mum]

I'd really stuggle to see how a previous physical injury ('m assuming it was a kick or fall) could go on to cause cancer in any location of the body - is that really what they are saying !?! If it was there are lot of people with broken legs who are in trouble in the future.

 

[alsxx]

Not exactly the same but I had 3 claims accepted by insurance co for a multiple lameness, they then changed their minds after accepting the claims and debated some of the conditions, I'd had to pay vet and was left heavily out of pocket!

Long story short, I got ombudsman involved whilst awaiting for the conclusion of the formal complaints procedure. The ombudsman remained in contact with me throughout the process so do get them involved now.

Mine was an apparently reputable broker too...

 

[cptrayes]

I'm really sorry for your problems but I think your insurance company may have a case. Injuries cause very fast cell replication to repair the injury. Very fast cell replication increases copying defects and there is evidence if you Google it that some cancer could be related. It would be an almighty coincidence if a very rare cancer happened directly at the site of a very rare fracture, wouldn't it?

Sorry I know this isn't what you want to hear, but it might not be wise to hold out your hopes too much for a pay out.

 

[derynw]

I would accept what you are saying if it was soon after the initial injury but we are talking 2 years later plus the initial fracture healed leaving very small bone enlargement that you would expect after any break or fracture, I have a few myself. From what I researched, and believe me I spent hours on google, a fracture can quite often be the first indicator of bone cancer in humans but has never been seen in horses please post the a link if you have found a case history in horses. don't think the fracture would have shown healing with just antibiotic treatment which was all he had if cancer had been present at time..
Yes it is a coincidence but they do happen and it wasn't directly at the same site just that the cancer spread to cover the fracture area as it developed.

Are you a vet/medic or work in the ins industry by any chance cptrayes?

 

[cptrayes]

I would accept what you are saying if it was soon after the initial injury but we are talking 2 years later plus the initial fracture healed leaving very small bone enlargement that you would expect after any break or fracture, I have a few myself. From what I researched, and believe me I spent hours on google, a fracture can quite often be the first indicator of bone cancer in humans but has never been seen in horses please post the a link if you have found a case history in horses. don't think the fracture would have shown healing with just antibiotic treatment which was all he had if cancer had been present at time..
Yes it is a coincidence but they do happen and it wasn't directly at the same site just that the cancer spread to cover the fracture area as it developed.

Are you a vet/medic or work in the ins industry by any chance cptrayes?

I've done a lot of work with insurance companies, for my sins. I suspect they'll fight your claim hard, adding to your upset about your horse.

I only found human stuff, nothing on horses.

 

[*hic*]

http://www.ncbi.nlm.nih.gov/pubmed/6480470

 

[ladyt25]

What was the cause of the original fracture?
Where is the cancer - did it start at the fracture site?
I can see why the insurance company are querying it but, I am not entirely sure they can backdate an exclusion if they have already agreed to remove it following receipt of evidence from a vet. That's just bad underwriting luck really as they made the decision to remove based on evidence they were given. had they stuff to their guns then fine, this wouldn't be covered.

It does seem rather coincidental that the cancer has appeared at the same site (if that's the case) and of the wording of the exclusion is along the lines of "injury/illness resulting directly or indirectly" from the original condition then they are within their rights to repudiate your claim.

However, if your vet (and maybe a 2nd opinion vet) could state they were pretty sure this was not related in any way to the original fracture then you may get somewhere.

I think if you sit back and think about it, you can see where the Insurance company is coming from - you've said yourself it is very rare so it does seem quite odd your horse could be that unfortunate! Don't get mad, just get your facts together, query the backdating of the exclusion -I don't agree with that. If the were saying you withheld a material fact they could void the policy. that is essentially what they seem to be saying - ie you omitted information. Going back and changing their minds about an exclusion doesn't sit right with me and was not something I'd ever done when underwriting horse insurance. You make a decision as an underwriter, if you get it wrong - tough! that's how the job goes!!

 

[Shrimp]

The cancer and the fracture are not at the same site, merely the same area. The cancer is located between the eye area and the fracture was about 2 inches above this.
I can completely understand them wanting to fight it like any insurance company but we lost confidence in the company near the beginning of the claim. After having a biopsy taken of the bone our vet suggested having a CT scan to see the extent. We contacted the insurance company to see if they would cover this. The suggestion we got back was that they thought the next step shoud be to take a biopsy, not a scan despite the fact they had been sent and received a detailed report from the vet on what had been done so far and his support for a scan. To us, it seemed that they had not read the report and just thought 'oh same area, its linked, won't pay out'.
Just because things are very rare doesn't mean they don't happen. For something that is so rare and there is very little information and research about, they dismissed the case very quickly. Vet has already stated they are not related and fracture was completely healed before cancer came about, we have numerous x rays to prove it. This will still be fought as long as we can until we are satisfied and we get the outcome we and and our vet agree with, whether it's the one we want or not.
P.s. Forgot to say to the beginning I am involved very closely in this, for a few weeks it was the most horrible, upsetting, stressful time and all this did not help our emotions at all!

 

[derynw]

The actual wording of the exclusion is 'all claims in connection with or relating to the fracture to the skull' not injuries or illness resulting. I think the exclusion is in some ways very open so it could be interpreted both ways. Vet has already stated In writing that he is of the opinion the two conditions are not connected so it appears to be a difference of opinion between professionals, one who has seen the horse in the flesh both times and one who has only x-rays and written reports. My vet has nothing to gain as he knows he will be paid regardless and is putting his own professional standing on the line to support us. He Is part of a large well respected practice and unlikely to risk it just for one client with one horse.
The retrospective change to the exclusion, they haven't actually stated that we withheld material facts just that the vet worded his statement regarding the healing of the fracture in a slightly different way, makes me think that they feel that the case for declining the claim without this is not strong enough to stand up through full complaints procedure and possible scrutiny by ombudsman.

I was not about them refusing claim, I expected that, but the retro change to the policy had me reaching for the phone for legal advice, know BHS gold membership would come in handy one day, and the advice given in regard to this was similar to above.

So,I will keep going. I don't get mad I get even!

 

[cptrayes]

Morally I feel they should pay. Good luck.

 

[Fjord]

Retrospectively changing the terms of your insurance seems very wrong. I do hope your horse is ok.

 

[ecrozier]

As per Jemima*askin's post, I think there is a documented history of cancer occurring around fracture sites or areas where bone has been affected somehow eg by orthopaedic surgery, certainly in dogs with osteosarcoma as we found with our dog. Which I think is the canine equivalent of what you are experiencing with your horse?
That said - retrospectively changing exclusions definitely doesn't seem on - can your vet assist in arguing your case perhaps?

 

[derynw]

Morally I feel they should pay. Good luck.

Thanks will post result but may be some time.
If they don't at least I know I will have tried my best and they will have lost a customer for life, including horse box ins as have no confidence in them now at all.

 

[Shrimp]

Our horse despite everyone's expectations recovered from horrific infections caused by investigating the lump (was nearly pts, spent 10 days in the vets, wont show you the gruesome pics ) and is doing amazingly well. It's taking a long time to build up him muscle and condition as he was antibiotics for nearly 3 months but last weekend he went out and won his two BD novice classes, he just has a bit of a lumpy head!

 

[derynw]

As per Jemima*askin's post, I think there is a documented history of cancer occurring around fracture sites or areas where bone has been affected somehow eg by orthopaedic surgery, certainly in dogs with osteosarcoma as we found with our dog. Which I think is the canine equivalent of what you are experiencing with your horse?
That said - retrospectively changing exclusions definitely doesn't seem on - can your vet assist in arguing your case perhaps?

Have looked at cancer uk website which states that there is no evidence to support the theory that bone injury can cause bone cancer, it is more that the injury occurs because the cancer is present. Have also found in my research that dogs with this condition have very poor outlook so could be if your dog had orthopaedic surgery then developed cancer the cancer was probably already there. Also unlikely that any damaged bone with cancer present would heal.
Sorry to hear your dog had this horrible problem.