What is "blind" in critical illnness cover?

churchrat

Hi


asking for a friend, who,as the title says, is now blind. He had a loan which was covered by an insurance company. He has lost most of sight and is registered blind. This is permanent and he has very little sight remaining. He was forced to give up work and claimed on the insurance.

The company refused to pay out because he was not "completely" blind. He was told that if he had taken out a policy with them 2 years later he would have been covered as they changed the requirement.

Does anyone think that he has any chance of appealing this decision? or is there any point in taking it to the ombudsman?

many thanks for reading

churchrat

ACG

If the policy conditions state total blindness and he isnt then no.
The company changing the wording of the plan at a later date does not effect the policy your friend took out. The premiums would most likely have changed also, so its probably not 100% accurate what the company are telling you.

dunstonh

We concluded that "sight" implied an ability to discern objects. On this basis we were satisfied that the policyholder had, for all practical purposes, suffered a total loss of sight. We required the insurer to meet the claim in full, together with interest, from the date of the accident.

The bit above is quoted from the FOS case in question. That to me is the key description. If it applies to your frient, then I would point the insurer to that particular FOS publication and case reference and state that if they do not apply the same principle that the complaint will be referred to the FOS and that FOS publication will be mentioned to them as well.

Whilst the FOS can be inconsistent at times (mainly as different people may have different views), if you point to a published case and decision and the explanation, it would be hard for them to take a differing view.

kingstreet

I regularly conduct reviews of critical illness definitions for other advisers. I recently looked at a high street bank's product from around 2005 against a new "adviser-type" product from today.

The bank product covered just 18 definitions and in all cases but one, angioplasty, the new product definitions were better and covered 37 conditions.

For example, the old plan's definition of blindness was;-

"total, permanent, irreversible blindness in both eyes"

against the new plan's definition;-

"permanent and irreversible loss of sight to the extent that even when tested with the use of visual aids, vision is measured at 3/60 or worse in the better eye using a Snellen eye chart."

Although some definitions have become worse, particularly when compared with plans taken out before 2001, many new plans are much wider in their coverage than those taken out in the last ten years.

I agree with Selden and dunston in considering it may be worth a FOS referral.

churchrat

Hi

many thanks for the replies. I have looked at the case and one reported on soon after, where the definition given by the FOS was wider than allowed by the insurer. I have advised my friend to go thro the complaints procedure with them, and make it clear that he will take it to FOS. He has only 2/60 in his "good" eye, and this is covered in the new policies the firm now sell.

His claim is for a great deal of money, over £50k, and I do not think that the insurer will just say "ok", altho it would be great if they did.

Does any one know how long it takes FOS to look at things??

Once again,
many thanks

Churchrat

magpiecottage

One of my clients had a customer make a blindness claim which took a couple of years to get through FOS.

However, that was decided in favour of the customer because the insurer attempted to rely on an exclusion which it was entitled to put in but drafted carelessly so that it said something other than what it meant to say.

The insurer said the customer should have realised what it meant to say but the Ombudsman was not impressed!