Critical Illness Claim Rejected

Ruby09

Thanks OshayAway. I appreciate the CI rules are there to cover only the most severe cases. However, there are specific blood test results and examinations that determine the severity by Rheumatologists - those cannot be exaggerated. My illness has always been in the extreme severe range.

Yes - own occupation TPD.

Thanks

OshayAway

Ruby09 wrote: »

Thanks OshayAway. I appreciate the CI rules are there to cover only the most severe cases. However, there are specific blood test results and examinations that determine the severity by Rheumatologists - those cannot be exaggerated. My illness has always been in the extreme severe range.

Yes - own occupation TPD.

Thanks

The problem can be the definition of severity. A consultant / specialist can describe a condition as critical or severe but these are subjective terms which is why the insurer imposes specific criteria so that there can be no ambiguity.

Have you considered claiming under the tpd element of the plan?

foggytown

lisyloo wrote: »

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.

Perhaps "inconsistency" wasn't the right word. Maybe "disingenuous" might play better. It's easy to be one of the very few CI providers that includes RA in the cover when the criteria are so rarely attainable that hardly anyone would qualify for cover.

lisyloo

Yes I can see what you mean.
If it's the employers policy then doesn't it mean the employer would have to pursue any complaint?
I am assuming that "provided through my work" means the employer is the party that has purchased the policy and not the employee although that might not be correct.

So wouldn't any course of action have to go via the employer?
I'm not certain an employee has a contract in this situation although it does depend on the exact circumstances.
If provided by mean the employee purchased it and is insured then that's different to an insurer purchasing a policy.

I have both at my workplace.
We have PHI where individuals are not specified and PMI which individuals choose to have and are named.

Ruby09

I added CI cover as one of my optional benefits. I received a policy cover note from Bupa and had to request my own claim form, which I completed and sent back myself. The company however had to confirm I was employed and what date the policy started.

lisyloo

I wouldn't know where you stand as I'm not a medical person, but it sounds like your own individual policy rather than the employers.

You can make a formal complaint via the insurers complaints procedure.
Ultimately you can take it to an independent ombudsman if that process if exhausted.
It will take some time, but would be free.

You could also search the financial ombusman site to see if there have been any similar cases.
It's certainly worth doing.
I've done it about 6 times and won, so companies are not always right in their decisions.

But can't offer nay help with the specifics I'm afraid. I think it would take an expert view.

Ruby09

Thanks everyone for your help. I think I'll give it some thought and see how things go.

Is there any advice on my future premiums changing? Or what would happen if I leave my current employer?

I aslo got CI cover for my husband under the same policy - for a small amount. Considering what's happened to me, I am thinking of increasing his level of cover. Would that be ok to do?

Thank you

lisyloo

Do you mean that you have made 6 successful complaints to the FOS?
That's an impressive record and it would be interesting to hear more.

Trying to remember as we are going back a bit.

1) First one was an endowment bought in 1991.
The projections we were given were 6%, 9% and 12% which were the correct expectations at the time, but we were told verbally to expect about 20% and those were really quite risk averse and only done for legal reasons.
This went to FOS. I suspect we won as the result of a commercial decision i.e. it cost more to argue with us that to pay.
We got compensation of about £1500 to put us back into the same situation as if we had taken a repayment mortgage.

2) Dual mortgage rates with Cheltenham & Gloucester. This was where they offered effectively two SVRs (one for existing customers and one for new customers) and this was overuled. I think this was in the 90's.

3) Dual ISA rates in the 90s with Britannia (same thing, dual rates for old/new customers). I think this didn't get as far as the FOS on an individual level but we won as the result of a similar test case.

4) Unacceptable mortgage exit fees with A&L of £250 when we were quoted much lower. This was waived completely.

5) Pension switch to technology fund early 2000's. This went to the FOS and this fund switch was not in-line with my expression of the level of risk I wanted. Got £3K back and also benefitted from some extra tax relief. (I think the compensation came back for gross pension but I could legally contribute it net so I actually profitted).

6) Had a fixed energy contract with Npower. I cancelled a DD. They took me off the fixed tarriff even though DD was not stated as a requirement. In fact the paperwork said you pay by other methods. Won at FOS and got £170 back for the extra I'd paid (I may have been slightly out of pocket here).

So all different ones and my memory is a bit hazy.
I don't give up.
I'd rather lose than not try because for me trying and failing still equals closure (knwoing I've done eberything I can). If I don't try then it nags away at me.

jd12343

Hi Ruby,

I am in the same situation as you - I have just submitted a claim but only meet 5 out of the 6 criteria.

Could you please let me know the outcome of your claim please.

Thanks

kingstreet

Looking at newer plans, the definition for Arthritis appears to have changed, so holders of newer cover may find making a claim easier;-

Chronic rheumatoid arthritis

A definite diagnosis by a consultant rheumatologist of chronic rheumatoid arthritis as evidenced by widespread joint destruction with major clinical deformity.

In addition the member must permanently satisfy three of the four following criteria:

Bending - The inability to bend or kneel to pick up something from the floor and stand up again and the inability to get into and out of a standard saloon car.

Dexterity - The inability to use hands and fingers to pick up and
manipulate small objects such as cutlery, including being unable to
write using a pen or pencil.

Lifting - The inability to lift, carry or otherwise move everyday objects by hand. Everyday objects include a kettle of water, a bag of shopping and an overnight bag or briefcase.

Mobility - The inability to walk a distance of 200 metres on flat
ground, with or without the aid of a walking stick and without having to rest or experiencing severe discomfort.

This is from the current Friends Life definitions.