Income Protection Insurance - can anyone help please

ana18

I have Income protection insurance with my employer and have been off sick with depression and anxiety for a while now. My employer's insurer took 5 months to make a decision and have just got back to me to say that they have concluded at this stage that the medical evidence does not support this definition '' [the insurance company] is satisfied that the member is unable by reason of illness or injury to perform the material and substantial duties of their insured occupation and is not following any other occupation”.
the medical evidence they have is from my GP who is signing me off work and from the occupational Health doctor (who also stated that I am not fit for work) They have not rejected me yet at this stage but I wonder how this can be the case and if it would be worth me asking more questions. Thank you all in advance.

lisyloo

Yes, you should appeal/complain.
It may be that your company has to do this as it's their insurance and not yours, so you may need to talk to the relevant people at your employers.
A lot will depend on how supportive your company are of your case.
In my view they should fight the case for you, but that depends on how good and supportive your employer is. You are in their hands.
But if the medical evidence says you are unfit for work then it seems worth appealing to me.

This is one of the downsides to relying on someone else's insurance.

ana18

Thanks a lot for your reply. My company is not supportive at all, they just say it is all in the hands of the insurance company and don't want to get involved. . Do I have the right to know why they've concluded this or can they just reject my claim with no explanation at all?

ACG

is satisfied that the member is unable by reason of illness or injury to perform the material and substantial duties of their insured occupation and is not following any other occupation”.

Am i reading this wrong? To me, it seems like they are saying you are unable to do your job, therefore that should mean theyre prepared to pay out?

magpiecottage

I think you are missing the point ACG. The OP says that is the definition and the insurer says they are not meeting it.

The policy is the insurers. However, they cannot appeal to FOS over it unless their turnover is less than £1 million per annum.

In theory, it may be possible for the individual to complain. They would need to argue that they are what is known as an "eligible complainant" - i.e. they are eligible to have FOS consider the complaint.

To do this, they would need to argue that they were a consumer (i.e. this relates to something outside their trade or profession). Although the policy is with the employer, I think they could reasonably argue this in the sense that the policy relates not to their profession but their inability to follow it.

This aspect is covered by DISP2.7.3R(1).

The insurer probably will not pick up on this point and is more likely to argue that the OP is not the insured. In that case they will need to remind the insurer of rule DISP2.7.6R(5) which makes a person for whose benefit a contract of insurance was taken out eligible to take a complaint to FOS.

ana18

magpiecottage, Thank you very much for your reply! I am noting down DISP2.7.3R(1) and DISP2.7.6R(5) even too early for that now as I haven't been rejected yet. My worry is that I think the insurance company are dragging their feet and not sure why. It took them 5 months to get this far (get all my medical records and two medical opinions and I made sure my GP and the other dr replied asap) and nowhere near a decision yet - they are saying that even they found out what I described above, that they want me to see their consultant (not sure why not reject the claim if they found out that I am basically fit for work despite two doctor's opinions)

What would you do at this stage?
What if I get better and go back before they make a decision or am made redundant (my company is going through redundancies at the moment) or decide to resign? What about those 5,6 months for when I was eligible to receive some payments. And how and why they concluded the above in spite of the evidence?!
What would you do at this sage? Off course I agree to see their consultant but can this just go on forever? Thank you very much in advance if you have a minute to reply to me

kingstreet

Are you still receiving salary payments from your employer?

What is the scheme's deferred or "waiting period" between being off work and benefits commencing?

ana18

Hi,

No I am not receiving any payments from my employer - the period was 6 months which was over 5 months ago. Thanks

magpiecottage

The policy normally pays to the employer, who then passes it on to the employee, less both employer's and employee's National Insurance and any income tax the employee must pay (unlike benefits under a personal policy, this is treated as earnings for income tax and NI purposes).

The period when you received sick pay from your employer will not count as the employer was paying you.

They are entitled to carry out their own enquiries to determine that you really are too ill to work but five months seems unreasonably long. Assuming you have complied promptly with any reasonable requests from the insurer, you would seem to have grounds for complaint.

As far as working is concerned, you will have to go back when your doctor says you are fit enough.

ana18

Sorry I wasn't very clear. I am hoping to go back to work as soon as I am better but my question is if this happens before the insurance company makes their decision are they still liable for the period I was unable to work? In other words it is very obvious to me that they are deploying delaying technics but I can't think why. Are there any circumstances in which they would become not liable (for the past 5 months) any more? If I am made redundant? if I resign?

Can anyone suggest the best course of action:

a) wait patiently until the final decision is reached and then complain if I think the decision is unfair.
b) complain now directly to the insurance company about the way they are handling my claim. Would I gain anything by doing this? They would probably say that they are not delaying deliberately, that they are sorry it is taking that long etc etc..

Thanks all so much, this has helped a lot!