Grateful for advice on critical illness cover

happypearl

Wonder if anyone has any thoughts on likelihood of successful critical illness claim. My husband had a stroke last year resulting in short hospital stay and 3 months off work - he is now back full time. He has continuing problems with fatigue, concentration, memory, physical pain and processing information. We took out critical life cover in Dec 2004 with Legal & General and our policy states that stroke must result in permanent neurological damage. Unlike more recent policies it does not specify he should have persistent symptoms nor mention how severe they should be. Can L & G impose the second clause or do they have to abide by the terms of the policy as it is written? Should we be feeling optimistic or prepare ourselves for a battle? Thoughts welcomed!

Oscar_The_Grouch

Hi there,

Sorry to hear about your troubles and your husband's stroke. I think it is worth you putting in a claim and getting the ball rolling. I believe the terms are set at the start of the policy.

The thing to remember is that the insurance company will rely on the evidence of experts in deciding the claim. This will involve medicals and examinations. You should always approach these with the "how I am on my worst days" attitude; they will report on the symptoms you present as well as what you tell them, so tell them how bad it gets!!!

Good luck with the claim.

webmasterpolo

Hi

I agree with Oscar. The terms will be the ones issued on your policy, it doesn't matter what the terms were the day before or the day after.

You should still try and claim though, as the worst they can do is say no.

-Web

happypearl

Thanks for your thoughts. We were being uncharacteristically optimistic and then read stuff about persistent symptoms. This, however, seems to be a clause that was commonly added to policies that were taken out after ours - ours just says permanent neurological damage. Given that a stroke causes a bit of the brain to die, is it over simplistic to hope that they will pay out without argument. He does, as I said in my first post, have ongoing disabling symptoms but tries very hard to work around these - what a shame if this counts against him. More thoughts!?

webmasterpolo

It will depend on the doctors report and how they interpret their T+C on whether you will get a pay out. No one can tell until the doctors report is done, he will be the one to assess the permanent neurological damage.

I would just put the claim in and see what happens.


-Web

pedro123456

Happypearl, having a stroke can present many symptoms and complications at varies levels, some (with time) may improve some may not improve and can obviously worsen, as you say its brain damage, you will have been told, I hope, improvement is possible with time however not guaranteed. I hope things go well medically.

As for your claim, first things first, as far as I am aware the IC cannot impose clauses added to policies at a later date, I may be wrong but I don’t think so, maybe a Insurance bod can confirms this for you.

Now here’s the concerning part, as soon as your claim hits the IC’s floor they are going to try and refute it, that’s the nature of the beast I’m afraid, as Oscar says they are going to rely on “evidence of experts”, however this will not be your Consultant Neurologist who diagnosed your stroke, it will be their claims handler (who probably has no medical knowledge at all) this is when you find out how good your policy is, and/or how underhanded your IC will be.

You will have to meet the IC definition of a stroke and also meet all the criteria as set down in that definition. You will then have to no doubt jump through more hoops for them in order for them to admit your claim.

Expect them to send for your full medical records (although they are not entitled to them), and expect your GP to send them (although he/she shouldn’t), then expect them to trawl through these medical records to avoid paying, i.e you broke a finger nail while washing the pots and you didn’t declare it when you took out the policy.

My advice would be to go through a claims company, who know what stunts the IC are going to try and pull in advance.

Despite your obvious difficulties at the moment, don’t for one second think the IC will show any favour or empathy at all, because they wont, they will do all in their power to avoid settling your claim……………good look

kevin_c_3

Unlike general insurance policies (car, home etc) protection policies such as critical illness cover are usually based upon the terms issued at outset - even if the policy lasts for say 20 years

Some providers have tried to push 'reviewable' definition policies over the years, thankfully without much success, but I'm not aware of L&G ever doing this, so in theory at least your claim will be based upon the wordings when you bought the policy

badger247

I would agree with what has been said here:-namely,

Put a claim in asap.

Do not accept what your IC decides first

If in doubt lodge a complaint with the Financial Ombudsman Service within the time limits. This is normally after you have exhausted the IC's complaints procedure.


I had a stroke at 34, 3 years ago. IC turned down my claim based on non disclosure. I accepted it, but fortunatley my wife did not!

2 years 10 months later and a complaint that the Financial Ombudsman took 2 years 2 months to conclude and the IC final paid out the whole amount plus interest!

Mortgage now paid and my family more importantly looked after should anything happen to me.


My advice, do not give up.

Badger

Myr

kevin_c wrote: »

Some providers have tried to push 'reviewable' definition policies over the years, thankfully without much success, but I'm not aware of L&G ever doing this, so in theory at least your claim will be based upon the wordings when you bought the policy

With respect I think you may be confused here between 'reviewable' and 'guaranteed' premiums (the amount paid by the insured per month/per year) which has nothing to do with the definition of the underwriting.

happypearl

Thanks Myr. So does that mean they can apply a new definition of stroke to our policy or do they have to go with it as it is written? I understand the ABI tightened up on some definitions since we started our cover but ours simply said "stroke - with permanent neurological damage" and does not specify nature or severity of symptoms.

Glad you succeeded Badger and hope you are making a good recovery. Interesting that they tried to wriggle out due to non-disclosure rather than on diagnosis - I am hoping that the silver lining to this horrible cloud will be that they have to accept that a stroke is a stroke (as confirmed through MRI scan) and pay.

pedro123456

"can apply a new definition of stroke to our policy"...............no..... your definition is the one that was in place at the time you took out the policy.............but be warned they are well capable of trying to implement a later definition

http://www.abi.org.uk/Information/Codes_and_Guidance_Notes/532.pdf

http://www.abi.org.uk/Information/Codes_and_Guidance_Notes/40737.pdf

http://www.abi.org.uk/Information/Codes_and_Guidance_Notes/527.pdf