Help with Claiming on Critical Illness Policy

Suzanne7173

I am new to this forum but could urgently do with some advice. My question follows on from the original post is critical illness worth it. We purchased our current home last year. We used a broker to source the mortgage, life and critical illness policies. My husband has recently suffered a period of critical illness. When we phoned our insurer they said that we were not covered. My husbands consultant, says that it was a critical illness and he underwent emergency life saving surgery. Having done some research I do now understand that critical illness only covers certain illness and then there is a Total & Permanent Disability clause aimed at covering those illnesses not falling under the main headings. My husband had ulcertive fulminant colitis. The description of what happens fits completley the following from the Prudential. Ulcerative Colitis shall mean acute Fulminant Ulcerative Colitis with life threatening electrolyte disturbances usually associated with intestinal distention and a risk of intestinal rupture, involving the entire colon with severe bloody diarrhea. Diagnosis must be based on histopathological features and surgery in the form of colectomy and ileostomy should form part of the treatment. They also cover Crohns disease, which affects many sufferers. My husband has managed to fight and has been sent a claim form but I am heartbroken thinking is this a case of bad luck and we were just with the wrong insurer? If we had been with the Prudential it looks like thet would have paid out. Any advice would be greatly appreciated.

somewhatnew

Hi

Sorry to hear about what your husband and your are going through - not good times.

A few things:
1. You mention 'if we were insured with prudential'. Who are you actually insured with?
2. What was the reason the insurer gave you that meant your husbands conditions didnt fit the criteria?

Regards

stephenni1971

Sorry to hear of your husbands illness... a few points.

Having done some research I do now understand that critical illness only covers certain illness

Were you not aware of what the insurance was when you took it out?

At the time you should have been provided with documentation from your adviser stating the reason why he was recommending the policy, and evidence of what it actually covered.

My husband has managed to fight and has been sent a claim form but I am heartbroken thinking is this a case of bad luck and we were just with the wrong insurer?

What insurer are you with? For critical illness there are many different variations of cover - but bear in mind the number of claims on your husbands specific condition is likely to be minute in comparison to the main conditions of heart attack, cancer and stroke. When faced with a number of different policies, each with slight differences in cover it's impossible to know what the future brings and so the decision has to be made on what was reasonable at the time.

When we phoned our insurer they said that we were not covered.

Have you actually made a claim yet? Regardless of what you were told on the phone you should put a claim in and then the insurer will have access to the full medical records surrounding the illness, and not just your description over the phone

The description of what happens fits completley the following from the Prudential.

There is no point in comparing to any other company. Do you have the full documentation of what you ACTUALLY have with your existing insurer?

It would help if you could tell us what policy you actually have.

OshayAway

If you don't have Pru Protects Serious Illness Cover there won't be any grounds for complaint against Legal & General. You're comparing apples and oranges. Pru's is a severity based cover so pays out on more conditions but instead of paying out the full sum assured benefit on any sucessful claim, pays a percentage of the benefit chosen at outset.

dunstonh

Critical illness cover has come in budget forms and comprehensive forms over the years. Plus, the conditions covered change over time. You are covered for the conditions you had when you first took out the policy.

You cant compare other providers as they may cover more or less. You cant compare the current business version with the version you have as the coverage may be different.

You should not rely on what you are told on the phone. You should submit a claim form. The telephone staff are generally not geared to giving the sort of information required to ascertain if you have a claim or not. They are not doctors.

You should ask your adviser that arranged the policy to help you as that is what they are paid for.

Suzanne7173

Thanks to everyone for taking the time to reply. I wish I had found this site years ago. In terms of our policy with Legal & General as far as I can tell it is a basic policy as our policy document matches the information held on the website:

What's covered by Legal & General's critical illness insurance?

Alzheimer's Disease - resulting in permanent symptoms
Aorta Graft Surgery - requiring surgical replacement
Aplastic Anaemia - with permanent bone marrow failure
Bacterial Meningitis - resulting in permanent symptoms
Benign Brain Tumour - resulting in permanent symptoms
Blindness - permanent and irreversible
Cancer - excluding less advanced cases
Cardiomyopathy - of specified severity
Coma - resulting in permanent symptoms
Coronary Artery By-Pass Grafts - with surgery to divide the breastbone
Creutzfeldt-Jakob Disease (CJD) - resulting in permanent symptoms
Deafness - permanent and irreversible
Dementia - resulting in permanent symptoms
Encephalitis - resulting in permanent symptoms
Heart Attack - of specified severity
Heart Valve Replacement or Repair - with surgery to divide the breastbone
HIV infection - caught from a blood transfusion, physical assault or accident at work

Kidney failure -requiring dialysis
Liver failure - of advanced stage
Loss of hands or feet - permanent physical severance
Loss of Speech - permanent and irreversible
Major Organ Transplant
Motor Neurone Disease - resulting in permanent symptoms
Multiple Sclerosis - with persisting symptoms
Paralysis of limbs - total and irreversible
Parkinson's Disease - resulting in permanent symptoms
Primary Pulmonary Hypertension - of specified severity
Progressive Supranuclear Palsy - resulting in permanent symptoms
Respiratory failure - of advanced stage
Stroke - resulting in permanent symptoms
Systemic Lupus Erythematosus - with severe complications
Terminal Illness
Third Degree Burns - covering 20% of the body's surface area
Total and Permanent Disability
Traumatic head injury - resulting in permanent symptoms

UC is not listed as a condition but the Consultant says that it was a critical illness and there are some elements of the Total & Permanent Disability part but it does not meet the full definition and would be subject to my husband having functional tests.

Prudential offer serious illness cover, which on face value looks a much better bet but there critical illness cover seems more comprehensive and includes at no 22 of there list UC. I know I have to move on and can't regress over the fact that our policy is with L&G and not the Pru. However, to me it just looks to be a case of we were with the wrong insurance company. I wish they were all standerdised. If you go to a broker and they are tied to Legal & General then you don't have any choice and it was at a time when getting a mortgage was becoming difficult.

somewhatnew

Unfortunatly it doesnt really matter what your consultant says - your contract is with L&G and not with the consultant. Ulcerative Colitis is not covered under the L&G contract, and to be honest and having looked down a comparison table I'm not aware of any companies other than Pru which would cover it.

You may be able to claim under the TPD element... but its tricky.

Remember to keep the existing cover in place, don't cancel it whatever you do, because if your husband tries to get cover elsewhere the colitis will have a big effect on the cost and even if he can get cover. L&G may not have covered the condition, but it is still a good policy compared to a number of other policies out there in the market.

pedro123456

Let me see if I understand this correctly, Suzanne.
You have CI with Legal & General, Ulcerative colitis is not a CI with them,
However UC is a CI with Prudential, therefore you wish you had arranged cover with them.

1-You ask for advice because your Hubbies Consultant said he had suffered a critical illness UC but in actual fact you IC don’t cover UC as a Critical illness.
2-You wish to know if UC could be covered under Total & Permanent Disability clause because L&G do not have it as a core condition

1-If your Insurance cover does not list UC as a Critical Illness then you cant make a claim for it
2-If the UC is such that it meets the definition of the L&G you can claim, however this definition of the IC (Total & Permanent Disability) I would have though caters for only the extreme cases Injuries/Illnesses.
In my opinion the IC would not have any of it, I may be wrong and hope I am, but I don’t think so.

People buy CI on the understanding that “if” they get diagnosed with a “condition” by their Doctor/GP/consultant and that this condition is alisted as a CI, that they are "covered"and in reality that isn’t the case.as a medical definition differs from a IC's definition.
Lets take UC, as you have some experience and knowledge of it.

Your husband has UC, diagnosed by his Surgical Consultant, he will have been on medication to address this condition for a while, he will have had all tests to confirm UC.
A Colonoscopy, History, blood results, possible histology, would have been enough for the diagnosis to be made.

However lets look at the IC’s definition.

Ulcerative Colitis shall mean acute Fulminant Ulcerative Colitis with life threatening electrolyte disturbances usually associated with intestinal distention and a risk of intestinal rupture, involving the entire colon with severe bloody diarrhea. Diagnosis must be based on histopathological features and surgery in the form of colectomy and ileostomy should form part of the treatment.

In this definition.

Abnormal blood results aren’t enough, they have to be “life threatening”
The abnormal results also have to be associated with “abdominal dissention with risk of intestinal rupture”
It has to affect the “entire colon”
“Surgery has to be formed as part of the treatment, and result in a ileostomy”

So in other words thousands and thousands of people have been diagnosed by their Surgical Consultants, as having UC, but the diagnosis is only accepted by the Insurance Companies if you meet “THE INSURANCE COMPANIES OWN DEFINITION IS MET.

There isn’t a medical definition that of any of the CI core definitions that are adopted by the ABI, and IC’s, without added embellishments.

Steph “
Have you actually made a claim yet? Regardless of what you were told on the phone you should put a claim in and then the insurer will have access to the full medical records surrounding the illness, and not just your description over the phone

The IC is entitled to only relevant PMH

http://www.abi.org.uk/Document_Vault...nce_FINAL1.pdf
Pease note this In Section 4

The ABI and BMA have developed a standard GPR form, which is available on the ABI and BMA
websites (www.abi.org.uk and www.bma.org.uk) and is widely used.

Only relevant information should be provided and it is ethically unacceptable to provide extraneous
information. Doctors must not send originals, photocopies or printouts of full medical records in lieu
of medical reports and ABI members should not accept them. The full records are not necessary and
will very probably include information that is not relevant to the insurance being applied for. Insurance
companies only need information that is relevant to the policy. Disclosure or other processing of
information that is released without the consent of the applicant or insured person is likely to breach
the Data Protection Act 1998, and may compromise a doctor’s registration.

Hope this helps clear a few things up Suzanne, is CI cover worth it?, well that’s up to the individual to decide.

As for UC you may find this site helpful
http://www.nacc.org.uk/content/home.asp


Z

cattie

I've suffered with Ulcerative Colitis & to be honest I wouldn't have considered it to be a considered critical illness under the terms of any such insurance policy, dispite what the consultant says.

If you'd had an income protection policy you may have been able to make a claim.

Isn't your husband expected to make a full recovery after recuperation or is he expected never to be able to work or do his job again?

pedro123456

ok Cattie, so you have UC, and if you had CI, that covered UC as a critical illness you would presume you have cover and expect settlement, correct?

Your Surgical consultant say's yep you got UC, the IC say "not our definition of UC you haven't" so no you aint covered

And they wonder why there isn't any public confidence in IC's

Z

somewhatnew

Pedro

Your missing the point of the thread.

This has nothing to do with consumer confidence. Stop trying to twist the issue.

The fact is the Suzanne7173 is seeking advice as to if she can claim on the policy. The short answer is no because UC is not covered, nor is it covered under any current Critical Illness Policy on the market (it may be covered under older policies but I don't have time to review old Technical Guides for the purpose of this thread). This is why TPD is there to catch any conditions not specifically listed.

Before you say ''well Pru Protect cover it'', their policy is not Critical Illness Cover, and they do not pretend it is, it is Serious Illness Cover (SIC) based on a sliding scale depending on how sick you are will give a proportionate payout.

Going back to Cattie's question and this is for Suzanne7173 - Isn't your husband expected to make a full recovery after recuperation or is he expected never to be able to work or do his job again?