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  • FIRST POST
    ellie43
    Critical Illness - A Dreadful Experience with Scottish Provident
    • #1
    • 23rd Mar 10, 1:03 PM
    Critical Illness - A Dreadful Experience with Scottish Provident 23rd Mar 10 at 1:03 PM
    I have read with interest the threads concerning critical illness.

    If you are considering taking out CI cover you may wish to bear in mind my experience. My policy is 'own occupation'.

    I first became ill in 1999 when I did not fully recover from a bout of flu. I was initially given a 'working diagnosis' of depression, undertook graded exercise therapy (GET), cognitive behavioural therapy (CBT) and was prescribed 6 different anti-depressants. As early as 2001 my GP notes indicate that ME/CFS was suspected. Also I reduced my hours at work to 20 hours a week, but my symptoms of physical and cognitive fatigue worsened. By April 2004 I was too unwell to work at all. In June 2004 I saw a NHS Clinical Champion with over 20 years experience who diagnosed severe ME/CFS and stated that it was very unlikely that I would be able to work again. In June 2005 I was awarded Ill Health Retirement as a result of the disabling effects of ME/CFS.

    In the Autumn of 2004 I made a claim under my critical illness policy with Scottish Provident. This was the start of a nightmare lasting over 5 years. SP sent a psychiatrist to 'assess' me who diagnosed depression, even though he said in his report I was not depressed when he 'assessed' me. This psychiatrist has claimed training in the field of ME/CFS but when repeatedly asked where this training was undertaken has refused to respond. This psychiatrist recommended concurrent CBT/GET and further antidepressant therapy.

    By coincidence NICE recommend CBT/GET for people with ME/CFS, but not for those severely affected by the illness. My claim was refused on the grounds I had not had 'optimal treatment of CBT/GET', delivered by an appropriately trained therapist. It should be borne in mind:
    1) That there are no such ME/CFS therapists in my region East Anglia, privately or on the NHS
    2) Even if there were I am not well enough to travel to access and participate in the therapy
    2) My ME/CFS NHS medical team did not recommend further CBT/GET in my case.

    Scottish Provident repeatedly refused to tell me what in their opinion my diagnosis is and what medical evidence they would accept in support of my claim. I asked them that in order to satisfy the policy would I have to undertake further CBT/GET by a therapist specialising in depression and also CBT/GET by a therapist specialising in ME/CFS. Scottish Provident refused to clarify.

    I made a DPA application to Scottish Provident who stated in their notes that I was refusing to engage in therapy and so get better. What I had actually said was that I would engage in therapies and treatment recommended by my NHS medical team.

    Getting nowhere I took my case to the Financial Ombudsman Service (FOS). The FOS told me I had to provide 'compelling medical evidence of total permanent disability', but refused to disclose what they meant by this. Insurers, by dealing with the FOS over a number of years, know exactly what is required.

    In an email to Scottish Provident (obtained under the DPA) I discovered that the FOS commented to Scottish Provident that it was clear I am very ill indeed, that the insurer would probably have to pay out, so why not pay out now?

    After deliberating for over 2 years the FOS ruled in favour of my insurer saying that although my consultant had stated 'I can state the certainty that this patient will never work again' my insurer was entitled to explore further treatments for depression. The FOS also said that my ability to understand the issues and my persistence is evidence of my ability to work. A real no-win situation, if I had not persisted my claim would not be paid.

    The FOS added that a way forward could be for me to obtain a further report from a psychiatrist commenting on my mental health.

    So I obtained a report from a psychiatrist specialising in the field of ME/CFS. He confirmed the diagnosis of ME/CFS, agreed with my first consultants opinion regarding prognosis and stated I am not depressed.

    I sent this report to Scottish Provident in November 2008 who continued to refuse my claim on the grounds that the psychiatrist had not included 'clinical objective evidence'. I asked Scottish Provident what they meant by this but they refused to clarify.

    By this time I had become very ill indeed. I decided I could no longer cope and chose to employ a specialist solicitor. He recommended obtaining further medical evidence from yet another ME/CFS Consultant. This I did last summer.

    At the beginning of this year Scottish Provident finally admitted my TPD claim dropping their insistence on further 'therapies'. It would appear that the involvement of a specialist solicitor and the weight of medical evidence finally persuaded Scottish Provident that their position was untenable.

    Over the years I have spoken to a number of people claiming PHI and TPD as a result of ME/CFS. Their experience has been uniformly poor. One lady was told by Norwich Union not to bother obtaining medical evidence as they would only take into consideration evidence provided by their 'experts'. I have documentary evidence (obtained under the DPA) that Scottish Provident lied to me and misled me. My NHS medical team has told Scottish Provident that their tactics have made my illness more severe.

    I see from some of the previous posts that a high percentage of CI claims are paid out. I suspect that this is the percentage of claims that are pursued. There is a proportion of legitimate claimants who simply give up because they are too poorly to cope with the tactics of their insurer and/or do not have the savings to pay for private medical reports and solicitors.
    Last edited by ellie43; 23-03-2010 at 4:01 PM.
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