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Critical Illness - A Dreadful Experience with Scottish Provident
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# 1
ellie43
Old 23-03-2010, 1:03 PM
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Unhappy Critical Illness - A Dreadful Experience with Scottish Provident

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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# 2
OshayAway
Old 23-03-2010, 2:18 PM
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Quote:
Originally Posted by ellie43 View Post
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.
No, the stats are from all claims registered. That includes the policyholder who rang the insurer to register a claim under the 'loss of speech' definition last year. An actual example which is included in the 'declined for not meeting the definition' figures.
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# 3
Molly41
Old 23-03-2010, 3:48 PM
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Thanks for sharing your experience. I am in a similar position myself. I dont have your conditions but it sounds a similar scenario. Would you mind if I PM you as I could really do with some advice on how to proceed? Many thanks
I must not fear. Fear is the mind-killer.
Fear is the little-death that brings total obliteration.
I will face my fear. I will permit it to pass over and through me. When it has gone past I will turn the inner eye to see its path.
When the fear has gone there will be nothing. Only I will remain.
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# 4
Molly41
Old 23-03-2010, 3:50 PM
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Is DPA data protection act?
I must not fear. Fear is the mind-killer.
Fear is the little-death that brings total obliteration.
I will face my fear. I will permit it to pass over and through me. When it has gone past I will turn the inner eye to see its path.
When the fear has gone there will be nothing. Only I will remain.
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# 5
ellie43
Old 23-03-2010, 4:21 PM
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Default Critical Illness

Insurers are happy to publicise claims such as the one that you mention, but are not prepared to put their house in order regarding the way in which they conduct claims in cases such as mine.There is no body which regulates this and in my experience 'treating customers fairly' is a farce. I would not have taken out the CI policy (and many others probably would not either) had I known that my insurer would refuse to tell me what medical evidence it requires, and from whom, to satisfy the policy definitions.
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# 6
ellie43
Old 23-03-2010, 5:14 PM
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Default CI Claim

Hi Molly
Have PM'd you!
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# 7
pedro123456
Old 23-03-2010, 5:18 PM
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Insurers are happy to publicise claims such as the one that you mention, but are not prepared to put their house in order regarding the way in which they conduct claims in cases such as mine.There is no body which regulates this and in my experience 'treating customers fairly' is a farce. I would not have taken out the CI policy (and many others probably would not either) had I known that my insurer would refuse to tell me what medical evidence it requires, and from whom, to satisfy the policy definitions.

correct on all accounts ellie , they want your premiums though
Campaigning to recycle Insurance Policies into Toilet Paper

Z
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# 8
jamesperrett
Old 23-03-2010, 5:25 PM
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Trudy Chalder has a great deal to answer for when she espouses CBT for ME/CFS. She seems to have convinced the NHS that it is the only treatment that works while conveniently ignoring the large proportion of people who don't respond. Unfortunately related bodies like your insurance company have also accepted her ideas.

My wife had severe ME for around 12 years and, while possibly not fully recovered, is now sufficiently well to work part time. She happens to be in the Mental Health business and is always commenting on how inappropriate many suggested treatments are. Having said that, she has found that certain psychological therapies are beneficial at the right stage of recovery - but never as a general cure-all for ME/CFS.

James.
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# 9
ellie43
Old 23-03-2010, 5:49 PM
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Default Critical Illness

Yes James, I agree.

It is interesting that the 'school' of psychiatrists who espouse CBT/GET for ME/CFS have close links with the insurance industry. The Chief Medical Officer for Scottish Provident who reviewed my claim for Scottish Provident was Prof Peter White who also heads the ME/CFS clinic at Barts. This clinic only 'treats' mild/moderate cases with - you've guessed it - CBT/GET. Even NICE doesn't recommend CBT/GET for the severely affected, yet that didn't stop PW advising my insurer that my claim should be refused until I undertook CBT/GET again.


Also it is very easy to blame the patient if CBT/GET is not effective, rather than looking more closely at the efficacy of the therapy. As my consultant commented there is no longitudinal research evidence that CBT/GET is remotely curative, or in the case of the severely affected can bring about enough of an improvement for the patient to return to work. The main problem with the research into the efficacy of CBT/GET is the selection of patients. A very wide definition of 'chronic fatigue' has been used, rather than for instance the Canadian Criteria for ME/CFS. There is a huge difference between 'chronic fatigue' and ME/CFS.

I am very pleased to hear your wife has improved, especially as she was severely affected. This illness can be very disabling and I wouldn't wish it on anyone.

Ellie
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# 10
OshayAway
Old 23-03-2010, 5:57 PM
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Did you get a payout in the end ellie?
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# 11
ellie43
Old 23-03-2010, 6:22 PM
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Default Critical Illness

Yes Oshay, I did get a payout - after 5 years and after I got a specialist solicitor from London involved. It was in the insurers interest to delay as long as possible as the policy was a decreasing lump sum designed to pay off a repayment mortgage.
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# 12
OshayAway
Old 23-03-2010, 6:32 PM
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I'm glad you did get the correct resolution in the end and sorry to hear you had such a frustrating experience over such a long time. You are quite right to state that this is not an isolated case. There are suggestions that TPD should be removed altogeather from CIC policies to avoid the issues / confusion etc. In which case a claim like you describe would not be upheld.

Out of interest, with the benefit of hindsight, do you feel you would you been better off saving the money you spent in premiums and not have the payout and all the hassle that went along with it?
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# 13
ellie43
Old 23-03-2010, 8:02 PM
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Default Critical Illness

Thanks Oshay. The problem with TPD is the gulf between the claimants perception of and the insurers view of the policy.

With hindsight I would not have taken out the policy. On balance the stress of the claim cost me a lot more in the deterioration in my health than the stress I would have had losing my income as a result of illness. I am lucky in that I get a small occupational pension, IB, DLA and my husband works full time. Being put under surveillance was especially unpleasant - the private detectives report commented on what I was wearing and doing in my living room.

My husband asked me on a number of occasions to give up. I did not do so partly because I didn't anticipate it taking over 5 years to resolve, but also because I believed I had a valid claim, backed up by medical evidence, and I didn't see why Scottish Provident should get out of paying up. However, I could not have persisted without the assistance of husband, friends my NHS medical team and the specialist solicitor.
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# 14
AlisonHarrison
Old 24-03-2010, 8:09 AM
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Ellie, I am trying to send you a PM but it keeps getting rejected.
Am wondering if it is because I do not have any posts.
Will try again once I have posted this.
Best wishes
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# 15
AlisonHarrison
Old 24-03-2010, 8:19 AM
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Default still cannot manage this

Ellie
For some reason I cannot send you a PM so I will have to put this on here.
My experience almost mirrors your experience exactly and I am in the middle of a TPD claim having been off work for 9 years now.
I think, like you I will need to hire a specialist solicitor and was wondering if you would give me the name of the specialist that you hired.
Thank you so much for your post.
Best wishes
Alison
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# 16
Molly41
Old 24-03-2010, 8:49 AM
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Hi Ellie,
Same here although Im only at the start really. Totally paranoid now that someone is watching me and my house

I hope you were able to get my PM because I asked the same re the solicitor. I would also like to contact them.
I must not fear. Fear is the mind-killer.
Fear is the little-death that brings total obliteration.
I will face my fear. I will permit it to pass over and through me. When it has gone past I will turn the inner eye to see its path.
When the fear has gone there will be nothing. Only I will remain.
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# 17
AlisonHarrison
Old 24-03-2010, 9:56 AM
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Quote:
Originally Posted by Molly41 View Post
Totally paranoid now that someone is watching me and my house
You are right to be paranoid.
I asked for all of my papers from my IC and have just today got them, and it includes a DVD of myself and a report of my movements
Was so so shocked. It was taken about 5 years ago.
They followed me for about 2 hours and I had not noticed. Could not believe it.
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# 18
Molly41
Old 24-03-2010, 10:16 AM
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OMG!!!!!!!

I think i might just give it up now!
I must not fear. Fear is the mind-killer.
Fear is the little-death that brings total obliteration.
I will face my fear. I will permit it to pass over and through me. When it has gone past I will turn the inner eye to see its path.
When the fear has gone there will be nothing. Only I will remain.
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# 19
Molly41
Old 24-03-2010, 10:18 AM
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Was that surveillance at the start of your claim? How scary.
I must not fear. Fear is the mind-killer.
Fear is the little-death that brings total obliteration.
I will face my fear. I will permit it to pass over and through me. When it has gone past I will turn the inner eye to see its path.
When the fear has gone there will be nothing. Only I will remain.
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# 20
AlisonHarrison
Old 24-03-2010, 10:30 AM
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Molly, please do not give up.
No the video was about 3 years into my claim.
I also got the report from the private investigator.
The IC's conclusion was that "there were inconsistencies with my reported illness and the video evidence, (rubbish!!) but not enough to stop the claim".
They tried to stop the IP claim a couple of years later, but I appealed to FOS and they lost.
The point is though THEY LOST.
Do not give up though, because unless the video evidence contradicts what you have told them, the FOS will not accept it. Look on the FOS website.
I am still reeling from the shock that someone followed me for two hours and I did not notice. It had my husband and kids on too.
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