Critical Life Cover - What Next?

Molly41

My claim under my critical life cover has been deferred for 12 months. What should I do in order to fight their decision? Should I appeal...how do i appeal? Should I ask to see their reports as they had to take advice on it or should I just give up? Im gutted as I have three reports i would not be fit to work as a midwife again and my critical claim is Occupational definition. Apparently even if i get retired they will still not pay out as they use different criteria.

Many thanks

OshayAway

Which insurer and do you have own occupation, any occupation or suited occupation TPD?

Molly41

Aviva and it doesn't define Occupation just occupational definition ?
Im a midwife which they know. Thanks

OshayAway

It might be worth asking. I beleive that Aviva apply midwives as class 3 (on a scale of 1 to 4, 1 being minimum risk, 100% admin etc). In which case own occupation definition would not apply here. However, that is not definately the case so, as I say, worth checking. Did you arrange your cover through a broker / IFA?

Molly41

Please could you clarify this last post? I dont understand what you are saying?

Many thanks

Molly41

Through Bradford and Bingley? A broker

OshayAway

Molly41 wrote: »

Please could you clarify this last post? I dont understand what you are saying?

Many thanks

Sorry Molly, my post wasn't very clear (I was in a bit of a rush). Basically, Aviva automatically include TPD (total and permanent disability) before age 60, on all their critical illness policies as standard, unless excluded by underwriting. Most other insurers provide it as an added option. In either case, one of these definitions is applied:

• Own Occupation - inability to carry out the main / any functions of your job
• Any Occupation - inability to do any job
• Suited Occupation - inability to do any job for which you are reasonably qualified
• Working Tasks - inability to carry out a minimum number of specified activities
• Activities of Daily Living - inability to carry out a specified minimum number of activities.

The definition applied is dependant on your occupation, so varies. An individual who works in an office, for example, is less likely to be prevented from working than someone who has more manual duties. This is why occupations are grouped into 4 classes, normally 1 & 2 get own occupation definition, the most valuable and comprehensive type.

At the opposite end of the scale, ADL definition requires severe disability to qualify. In the case of Aviva, you need to fail 3 or more of the following:

1. Transferring
2. Continence
3. Dressing
4. Mobility
5. Feeding
6. Washing

(These are the current definitions, which may be different from yours) The specific criteria for these are found in the 'Guide to Critical Illness Cover' booklet.

In any case, the disability has to be permanent, taking into account current medical knowledge and technology.
As you can probably gather from the above, it’s rare to get a quick decision on claim for TPD.


It's a shame you don't have access to your broker.

Molly41

My policy is own occupation as a midwife. I dont understand as I have three consultants saying I cant work as a midwife again. Is there a booklet or any info that can help me fight this decision? Its so complicated? I really dont know where to start and feel very daunted? Anyone with experience of this?

Many thanks for responses so far.

OshayAway

Molly41 wrote: »

My policy is own occupation as a midwife.

Have Aviva confirmed that in writing since your claim?

Molly41 wrote: »

I dont understand as I have three consultants saying I cant work as a midwife again.

It's possibly due to the 'permanent' part of the definition, or at least often is. If there is the possibility of improvement in future, that can have a bearing on the claim and a reason that the underwriter may want to wait to get a more accurate prognosis in 12 months.

At the very least you can ask exactly why the decision to postpone has been made.

ellie43

Hi Molly
I have been through this over the past 5 years with Scottish Provident. (I put up a thread today for MSE's to review) My policy like yours was 'own occupation'. If you have good medical evidence, preferably from consultants which confirm:
1) your diagnosis
2) that treatment options have been explored
3) prognosis
Then you may wish to consider making a complaint to the Financial Ombudsman Service. It's free but they are slow and staffed in part by people who used to work in the insurance industry. The insurer is bound by the Ombudsman's decision, but you are not.

I would also consider making an application under the Data Protection Act for copies of the information that your insurer hold on you. This gives you an opportunity to correct anything that is incorrect, and can also give insight into their chief medical officers response to your reports. If you find that the shots are in fact being called by a re-insurer e.g. Swiss Re, make a DPA request to them to. A warning though, you may find comments written by the insurers staff that upset you.

In my experience these claims hinge on the medical evidence. In addition you will need to counter any medical evidence obtained by the insurers 'experts' with a consultant of your own in the same field.

Don't give up though. You need to be prepared for a long haul with this. PM me if you need more info.