Critical Illness Claim Rejected

cju857arh · 20 July 2017 at 1:49PM

Hi,
I've had a critical illness claim rejected and I'm wondering if its worth appealing or not?

So, had a lump 8 years ago and had been to doctors 5 times since then, every time the doctor saying its a scar tissue.

I took a new job June 2016 that came with private medical care.
On the 4th of August took out my personal benefits / salary sacrifice from the company; critical illness for me and my wife, childcare vouchers etc etc

Because I had private care i went to NHS GP mid august to get referred about my lump due to annoyance of it and wanting it removed.

I had it removed late August, diagnosed 2-3 week of September that the lump was melanoma and had gone 8 mm through my skin.

Put a claim in with my critical illness company and they rejected on the basis that if i had gone to the doctors in September they would have paid as that's when my cover started 1st September.

So my reasons for thinking about claiming are that;
the online forms we all done via company intranet, so no adviser was present.
When asked about pre-existing conditions or awaiting diagnosis results i put no because i wasn't waiting for any.
I was not advised or its not mentioned that any diagnosis procedures done on dates between submitting the online form to the cover start date (1st September) would not be covered. I cant help feeling that if i had been sat with an adviser they would of highlighted not to go to the doctors about non emergency procedures etc.

If i'm honest i'm not that bothered about missing the critical payment (yes would be nice etc) but now my cover does not include Any cancers now because its preexisting condition, but my premiums are the same... Its not like i took my CI out because i thought oh i'm getting a lump removed.

So is it worth appealing / thoughts.

Thanks
CJU

Weighty1 · 20 July 2017 at 2:47PM

If you chose your salary sacrifice benefits on 4th August how come your critical illness plan only started on 1st September? Was it a self-selected start date?

As an aside, the insurer cannot really be held responsible for you not having an adviser present. It is their job to provide the insurance and nothing more.

Is it worth appealing? If the cover hadn't started when you had this procedure I can't see the grounds for appeal. As previously stated, it's not the insurance companies job to provide you with an adviser, so what would your grounds for appeal actually be?

cju857arh · 20 July 2017 at 4:35PM

The agreement automatically starts on the next calendar month. However it does not state that any diagnosis that occurs between date being accepted and policy start date is not covered.

jonesMUFCforever · 20 July 2017 at 7:02PM

I don't understand how you could have put NO to pre-existing condition when you have seen a doctor 5 times about the lump.
You may not have been waiting for any results but I certainly would have mentioned it in any application.

I hope however that you are now getting back to good health - good luck with any appeal.

Weighty1 · 21 July 2017 at 9:57AM

cju857arh wrote: »

The agreement automatically starts on the next calendar month. However it does not state that any diagnosis that occurs between date being accepted and policy start date is not covered.

I'd be surprised it is doesn't mention this in their T&C's somewhere as this is probably something which group critical illness providers come up against on an all too regular basis. Why not ask them to point out where it states this in their terms and conditions?

Quentin · 21 July 2017 at 11:17AM

cju857arh wrote: »

The agreement automatically starts on the next calendar month. However it does not state that any diagnosis that occurs between date being accepted and policy start date is not covered.

As you say, the contract didn't start from the date of application.

Thus (just like most other policies) if there's a material change in circumstances before starting all bets are off!

starrystarry · 21 July 2017 at 8:04PM

Quentin wrote: »

Thus (just like any other policy) if there's a material change in circumstances before starting all bets are off!

Not strictly true. I know of at least one insurer where the duty of disclosure ends on the date the application is submitted, rather than the date the cover starts.

Quentin · 21 July 2017 at 8:48PM

Edited the word you not happy with.

LadiTreblings · 7 December 2017 at 6:24PM

I think the issue is this: "Because I had private care i went to NHS GP". If you had gone because you noticed some physical change after the cover was arranged, the I would say it might not be a pre-existing.

Hope you're back to full health.

Critical Illness Claim Rejected

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