Critical Illness Payout after Stroke

Rodney74

Does anyone have any experience of an insurance company NOTpaying out a critical illness payment after suffering a stroke? On September 4thlast year, my wife suffered a stroke with no warning whatsoever. She wasimmediately rushed to a specialist neuro unit and a platinum coil was insertedinto her head the following day to stop the bleed. She has paid her criticalillness payments religiously and how this can be argued as not critical isbeyond me. If it were not for the metal in her brain then and now, she would bedead!! That notwithstanding theinsurance company have said that they will not pay out. We have complained andthey intend to review the case and will get back to us within 8 weeks. All inall a very traumatic and stressful period which continues with the attitude ofthe insurance company and to be honest is hindering my wife’s recovery. Hasanyone had any similar experience or can offer any advice.

InsideInsurance

Critical illness is not a good name for the policy, in my mind anyway. More accurately it is an insurance against a specified list of conditions and a required level of severity for each of them.

Stroke is on the list of all the policies I recall seeing but that isnt to say it is on all of them. Have you read your policybook to check if it is listed and if it is, if there are any required levels/ tests it must pass?

Have they simply said that strokes arent covered by your policy or that it was not at a sufficient level to trigger payout?

weighty1_2

Unfortunately, I do not have any experience about a cic plan not paying out for a stroke, however, the following definition below is what the Association of British Insurers lay down as being a positive definition for a claimable stroke.

Stroke – resulting in permanent symptoms
Death of brain tissue due to inadequate blood supply or haemorrhage within the skull resulting in permanent neurological deficit with persisting clinical symptoms.
For the above definition, the following are not covered: Transient ischaemic attack. Traumatic injury to brain tissue or blood vessels.

So was the stroke in your wife caused due to an accident? And was it definitely a stroke and not a Transient Ischaemic Attack (TIA).

I am just wondering what the reason is for the insurer saying they will not pay out? Is it due to the stroke itself, or another issue such as not disclosing some fact of importance on the application form?

Here's to a quick and speedy recovery for your wife.

OshayAway

Industry-wide, strokes account for the 3rd most common cause of critical illness claims, behind cancer and heart attack.

The treatment and potential repercussions of not being treated do not have a bearing on the validity of a claim. There should be a specific reason given for the decision, have you been furnished with that?

longtimelurkersam

Unfortunately I have plenty of experience when I was adjudicating these types of claims (15+years) both for the insurance companies and reinsurance companies. It really all falls down to the wording and whether for example you might think and been told it is a “stroke” (layman’s terms for ease of diagnosis) but it is in fact something else like a transient ischaemic attack (TIA). The minor differences don’t mean much to you but they do the insurer who has priced the policy to only cover X and not to cover Y for example.

Without the full details it is impossible to know, so it is up to you to decide if you want to put the full reason on here. One thing that was common was for claims to be turned on was the lack of a permanent neurological deficit (PND). Now one view is that if part of the brain has been starved of blood it will be dead and therefore there will always be a PND even if other parts of the brain are compensating for it and it is not evident on examination. Another view is that if the brain has adapted then there is no PND.

If the PND excuse is used it is surprising to find how many sufferers of declined claims suddenly experience minor memory loss or some other neurological deficit…………I am not suggesting this just commenting on my experience.

You don’t have to answer the question on here, but what is the value of the policy and who is the company? If it is significant then the claims decision will not have been made by the insurance company alone. All of these policies are reinsured by reinsurance companies and their claims team will be guiding the decision on high value/tricky claims. If it is high value or a really tricky diagnosis/claim it is unlikely that any decision will have been made without reference to the insurers and the reinsurers Chief Medical Officer (CMO’S). The reinsurers in particular will use eminent neurologists or professors in neurology as their CMO’s who will strictly interpret the wording of the policy as it is the specific wording of your policy that you have paid the premium for and they will not pay a claim if the wording is not satisfied.

8 weeks is the standard complaints handling time for a case before you get Ombudsman’s rights however this doesn’t help you right now.

If you don’t want to share items on here PM me and will happily provide you as much guidance that I can.

kingstreet

It's going to be difficult for the insurer to claim this is a TIA if there was haemmorhaging. The difference between the two types of stroke is one is based on a blood clot (ischaemic), and the other on a bleed (haemmorhagic).

We need more information from the OP before drawing any conclusions, but he should use the complaints process as mentioned earlier.

longtimelurkersam

Indeed. I wasn't suggesting they were. It was merely an example as the general public often do not fully understand the diagnosis when discharged And often just call it a stroke, or a mini stroke as it is easier to explain to other lay people.

The knowledge of the Op suggests a better understanding than most.

kingstreet

My post wasn't aimed at you, or in answer to yours.

I think it was more in reply to weighty, TBH.

Rodney74

Many thanks for all the responses so far and hopefuly I can answer some of your questions. It was not as a result of an accident or trauma in any way. Literally standing one minute, on the ground the next with an unbelievable headache (since this, have reserched and found the term 'thunderclap' used as a description). It is also certainly not a TIA, but was classed as a haemorrhagic stroke. As for permanent neurologigal damage (as you say this is mentioned in the policy document) my wife now has a metal coil in her head, she has pins and needles down one side and there are days when she can hardly lift her head off the pillow. We literally wait till each morning to see if it is going to be 'good' or 'bad' and no one knows whether this will get better or worse. We really do appreciate the responses so far and if there is any further advice/suggestions it would be much appreciated. Thanks

Quentin

Rodney74 wrote: »

.... We have complained andthey intend to review the case and will get back to us within 8 weeks.......

You have done the right thing.

Their response will hopefully either reverse their decision or fully explain why they are unable to honour the claim.

If you are unhappy with their response, then you can escalate to the FOS.

As far as the stress of all this is concerned, then be prepared (and prepare the patient) for many months of delay if you do end up escalating this to the fos, as they do move very slowly. (Months not weeks)

longtimelurkersam

What does the letter state as the reason for declinature?

One thing you might want to do is a pre-emptive Subject access request under the Data Protection Act. This will give you their case file (medical papers should go to your doctor) so you will be able to fully understand the reasons behind their decision.

You may not need this file if the complaint is found in your favour but at 8 weeks if you have no resolution from the insurer you will at least be in the best position to place your case to the FOS. It is a small fee and will help you understand a bit better.

Insurers get a bad press generally buy my experience of most people who assess these claims are that they are good people interpreting restrictive terms and conditions and applying these to people in unfortunate circumstances. That doesn't help you I know.

as your wife is recovering and not working are they waiving premiums (if you had that as an associated benefit and any deferred period has elapsed). When/if claim is settled they should refund all paid premiums back to date of diagnosis.

Ps hope she recovers suitably well.