A 92-year-old woman with multiple serious health conditions and disabilities is facing an uphill battle with her insurer, Axa, over her urgent medical needs.

Last year, she suffered a fall resulting in a broken hip, necessitating emergency surgery through the NHS, which involved the insertion of a screw. Unfortunately, complications arose as the screw dislodged, leaving her in significant pain and hindering her recovery.

Her son, a physician based in Florida, recommended a highly regarded consultant orthopaedic surgeon who specializes in minimally invasive hip surgeries, understanding that his mother cannot undergo general anesthesia due to her health issues, which include a pacemaker, hypertension, and diabetes. This specialists’ assessment emphasized the urgent need for the screw’s removal and the replacement of her hip.

Following this consultation, a request was made to Axa for a CT scan, guided ultrasound, and necessary blood tests. The claims team verbally approved these requests, stipulating that her surgery would be covered provided a specialist referral from her doctor was obtained. However, since the chosen surgeon is not listed among Axa’s approved surgeons for such procedures, Axa has indicated that the patient must contribute approximately £2,500 toward her treatment.

Despite securing a referral from her rheumatologist, Axa’s claims department has now reversed its position, stating that coverage for the recommended surgery is not available. This situation has caused significant stress for the elderly woman, exacerbating her existing health concerns.

Her family maintains that no other surgeon offers the same level of expertise and success rates that this particular surgeon does.

In response, consumer advocate Jill explains that Axa’s policies are structured to favor certain specialists for various treatments, similar to auto insurers who prefer using specific repair shops to minimize costs. Axa reported that it typically pays around £800 for hip replacement surgeries, while the surgeon recommended is known for charging above this rate.

After some advocacy, Axa agreed to cover £800 towards the surgeon’s fees along with associated costs such as anesthesia, hospital accommodation, and other necessary expenses. Additionally, Axa offered a £250 goodwill gesture.

The article also highlights other troubling customer service experiences, including issues with British Gas related to a massive billing increase and difficulties with account closures after a customer’s death. Many customers have cited ineffective complaint handling and poor communication from British Gas.

In both cases, the guidance from regulatory bodies like Ofgem was used to challenge unfair billing practices and push for rightful refunds, revealing systemic issues within customer service operations in major utility companies.

Readers have been encouraged to reach out for assistance with similar issues to ensure their concerns are addressed.