Critical Illness Claim Rejected

Ruby09

Hello,

I was looking for some advice on a critical illness claim. The policy is provided through my work. I was diagnosed with seropositive Rheumatoid Arthritis (RA) earlier in the year which is specifically covered in my policy. Whilst my condition has been confirmed by a consultant and the insurer has accepted the diagnosis, they have declined my claim as I don’t meet all 6 of the conditions that define the disability. However, not all conditions occur within the first year of diagnosis. I’d like advice on whether this is something I should appeal?

The criteria of the policy are the same conditions as the ones defined by The American College of Rheumatology (ACR). Although only 4 have to be met to be defined as RA by the ACR:
1 - Morning stiffness of >1 hour most mornings for at least 6 weeks
2 - Arthritis and soft-tissue swelling of >3 of 14 joints/joint groups, present for at least 6 weeks
3 - Arthritis of hand joints, present for at least 6 weeks
4 - Symmetric arthritis, present for at least 6 weeks
5 - Subcutaneous nodules in specific places
6 - Radiological changes suggestive of joint erosion

I meet conditions 1-4 (possibly 5 as my xrays were baseline xrays before diagnosis and I’ve not had any recent ones). As the ACR confirm RA based on 4 of the criteria, it seems odd that my insurer can claim that I have to meet all 6 conditions.

I don’t have subcutaneous nodules – however my research shows that 1) it can take years for these to be visible, 2) are mostly common in smokers (which I am not) and 3) only occur in 20-30% of patients. My RA has been classified as severe and is still not under control after 10 months of treatment.

My insurer has advised that if my condition changes they are happy to reconsider the application.

As well as seeking advice on appeal, I would also like advice on how this affects my policy? As it’s provided through my employer, what will happen if I leave my job on medical grounds, before I have met all conditions – my policy will cease and I will not receive a payout. Statistics show that 33% of sufferers will not be working within 5 years, so I am extremely concerned for my future (I’m only 30). Will they also try to increase my premium as they now have knowledge that I am likely to meet their definition at some point in the future?

Ironically, I am in receipt of DLA and have a blue badge due to RA disability.

Any advice will be greatly appreciated.

Thanks,
Ruby

Andy_L

Ruby09 wrote: »

The criteria of the policy are the same conditions as the ones defined by The American College of Rheumatology (ACR).

That implies you are an American, as this is a UK site I'm afraid it's unlikely anyone will be able to help due to the difference in UK & US law/insurance regulations etc.

EDIT: Which is contradicted by being on DLA & having a Blue Badge, being a bit of a numpty there :-(

OshayAway

I've never heard of a critical illness plan covering Rheumatoid Arthritis. It certainly isn't an ABI condition. Which insurer is the plan with? Is it a pruprotect serious illness cover policy?

dunstonh

I've never heard of a critical illness plan covering Rheumatoid Arthritis.

I'm pleased you said that because I was racking my brains trying to think of a provider who would offer it on CI. Certainly could fall under PHI as a wider illness but not CI.

Ruby09

Hi,

No I'm in the UK - the policy is with Bupa. Details are on their website - the condition covered is: Chronic rheumatoid arthritis – of specified severity. It's not on very many CI policies as it's covered under TPD nowadays I think.

Thanks

foggytown

Firstly, since you say this cover is provided through your employer, you need to speak to whoever within your company bought this policy and ask them for their take on it. That person should be knocking down BUPA's walls demanding an eplanation for the apparent inconsistency. If it is a group plan, and there are a number of employees in it, there may be some muscle your employer can wield.

lisyloo

That person should be knocking down BUPA's walls demanding an eplanation for the apparent inconsistency.

Where is the inconsistency?
The cover is for a severe condition and the OP doesn't meet all the criteria.
Although it seems harsh (cover is for severe), it doesn't seem inconsistent to me, it seems quite clear.
I realise it must be very hard for the OP and I'm not trying to be nasty, but I don't see any inconsistency, it seems very clear.

Please educate me.

Ruby09

Hi Lisyloo,

I agree - I don't meet all conditions therefore they can reject it. My point however is that many sufferers with severe and chronic RA will never get subcutaneous nodules. Therefore are the policy conditions unreasonable?

In addition, for those that do get them, they don't appear for many years after onset.

Thanks

OshayAway

Ruby09 wrote: »

Hi,

No I'm in the UK - the policy is with Bupa. Details are on their website - the condition covered is: Chronic rheumatoid arthritis – of specified severity. It's not on very many CI policies as it's covered under TPD nowadays I think.

Thanks

Do you have own occupation TPD on your policy?

OshayAway

Ruby09 wrote: »

Hi Lisyloo,

I agree - I don't meet all conditions therefore they can reject it. My point however is that many sufferers with severe and chronic RA will never get subcutaneous nodules. Therefore are the policy conditions unreasonable?

I think that's the point. The insurer details specific criteria to ensure that only the most severe (critical) cases are eligable. Possibly, also because criteria 5 and 6 can be independantly evidenced. I'm not suggesting this applies to you but insurers need to protect against fraudulent claims and criteria that is based on pain / discomfort felt can easily be feigned or exagerated.

lisyloo

Therefore are the policy conditions unreasonable?

I have no medical knowledge.
But I don't think it follows that it's unreasonable, just because the policy only offers cover for the very worst cases.

I guess it comes down to the wording given, but the wording "specified severity" seems quite clear to me.

Have you actually discussed this with your employer?

My husband's company have private medical insurance and when one lady was turned down for cancer treatment, they got involved and then she got treated on the policy as they weren't happy about her being declined (I don't know the details but with hundreds of staff it could have been a commercial decision).