Critical Illness Claim

quietheart

I claimed on 2 insurance policies a while back. One paid out, the other didn't.
I am having the refused claim looked at again, they want more evidence, my consultant is being terribly vague and said he didn't have enough evidence, his diagnosis was clinical and he said I should be careful about having it investigated in case the first insurance company (who did pay out) change their mind and ask for the money back?!!
Can this happen, they've made their decision on evidence provided so surely they can't change their mind?
Should I pursue the other claim, it's an odd situation to be in, any advice would be gratefully received.

somewhatnew

The CIC policy pays out on defenition of a specific condition being met. It is possible that the two insurance companies had different criteria for the insurance to pay out.... is the wording exactly the same when you look at the respective CIC Technical Guides (not the Key Features - its a different document) for the policies you have?

If the medical evidence confirmed the condition then the isurance pays out. It is a one way insurance contract, there is no clause that is inserted that you have to repay the money if you recover or have a wrong diagnosis.

I would suggest get a copy of the CIC Technical Guide from the insurer or your broker, send the correct page to your consultant asking specifically, 'does my condition meet this criteria?'. If he says 'yes' then persue the claim, if 'no' then leave it or seek a second option, if the response is 'maybe' then seek further clarity.

Hope that helps

dunstonh

The CIC policy pays out on defenition of a specific condition being met. It is possible that the two insurance companies had different criteria for the insurance to pay out.... is the wording exactly the same when you look at the respective CIC Technical Guides (not the Key Features - its a different document) for the policies you have?

This is key. CIC policies are not all the same. Historically you have budget ones and comprehensive ones. You also have some that cover far more than others. Even today there is a minimum ABI standard but many companies go beyond that but in different areas.

So, just because one pays out, doesnt mean another will as it may not cover that. Without details we cannot say what was covered and what wasnt but your IFA (that your purchased through) should be able to help you and the insurance companies should be able to clarify why they are refusing and you can compare that to the wording of the one that isnt paying out.

pedro123456

Rovers as Dunstonh as said, the IC may have different definitions, I would be surprised though if they are that different IF they both used the definitions that applied when you actually took out the policy

IC’s change their definitions, basically ppl put in claims, and if too many claims are paid they decide the definition can’t be stringent enough and therefore made them harder to attain.

It’s possible that one of your IC has used a more recent definition to assess your claim.

So…………write to your IC………..ask for a definition of your illness that WAS APPLICABLE AT THE TIME YOU TOOK OUT YOUR POLICY take that definition along with this…………………….. http://www.abi.org.uk/Document_Vault/2008_BMA-ABI_Guidance_FINAL1.pdf to your consultant and ask if (as somewhat advises) if you meet the definition.

If you can send me a private message saying what your condition is and when your policy was taken out I MAY have the definition the ABI were recommending at the relevant time, don’t make any bones about it, if they can get away with using later definitions as one of their many “get out clauses and or loopholes” they will.

Pete

OshayAway

Policy definition changes are irrelevant as the contract is formed at the time the cover is taken out. Your policy documentation and policy summary will show which conditions are used to asses the validity of your claim.

If a claim is declined the insurer is obliged to provide specific reason why. Armed with that information and the claim criteria, your consultant should advise you if he agrees with the decision or not.

pedro123456

"Policy definition changes are irrelevant as the contract is formed at the time the cover is taken out"

Changes aint irrelevant when they attempt to impose a later definition than that definition the was in place at the date you take the policy on are they.
As I stated above they do try to impose later definitions of CI claims in order to avoid payment of that claim.

And they aint irrelevant when the IC base your claim against the criteria within the definition.

I repeat......…………write to your IC………..ask for a definition of your illness that WAS APPLICABLE AT THE TIME YOU TOOK OUT YOUR POLICY take that definition along with this…………………….. http://www.abi.org.uk/Document_Vault...nce_FINAL1.pdf to your consultant and ask if (as somewhat advises) if you meet the definition.

ps.................inform the IC that just because they state in their T&C that you have to wear sky blue thongs with spots on 24/7 it doesn't entitle them to throw a none disclosure loophole at ya.

Pete

OshayAway

pedro123456 wrote: »

"Policy definition changes are irrelevant as the contract is formed at the time the cover is taken out"

Changes aint irrelevant when they attempt to impose a later definition than that definition the was in place at the date you take the policy on are they.
As I stated above they do try to impose later definitions of CI claims in order to avoid payment of that claim.

And they aint irrelevant when the IC base your claim against the criteria within the definition.

I repeat......…………write to your IC………..ask for a definition of your illness that WAS APPLICABLE AT THE TIME YOU TOOK OUT YOUR POLICY take that definition along with this…………………….. http://www.abi.org.uk/Document_Vault...nce_FINAL1.pdf to your consultant and ask if (as somewhat advises) if you meet the definition.

ps.................inform the IC that just because they state in their T&C that you have to wear sky blue thongs with spots on 24/7 it doesn't entitle them to throw a none disclosure loophole at ya.

Pete

Utter nonsense

OshayAway

The whole point of the insurer providing policy conditions from outset is so that both parties have a record. This makes up the contract along with the disclosures on application.

The prospect of challenging policy conditons with the ABI is obsured as all policied have to conform in order to be licensed as critical illness plan.

As for non disclosure loopholes, there is nothing to be concerned about there as long as you answered the applications truthfully.

staffie1

when I took out my policy I was told I could only have 1 policy covering the same thing - ie critical illness, income protection, etc. Maybe that was just a marketing ploy...?

dacouch

Can we all quit with the insults apart from the fact its against MSE rules its ruins the advice or discussions on each thread. By all means have a heated discussion but there is no need to insult each others intelligence. Everyones is entitled to voice an opinion on MSE, if you do not agree with their opinion respond to it but don't insult each other

pedro123456

ok dacouch, you have a good point, I have no desire to exchange with Osh in anyway actually...i'll leave it at that........

Pete