Failed income protection claim

ambler

My partner took out a personal loan at the bank and was told she also should have income protection insurance. Although this was not compulsory she took out an income protection policy and six months later was off work for six weeks following an operation for a carpel tunnel problem in the left wrist.

Her claim on the insurance was turned down. The insurers asked for her medical notes from her doctor and because these notes showed that she had had a pain in her arm in the past they claimed “pre-existing condition”

The point is that the problem had never previously been diagnosed as carpel tunnel and it had not been disclosed. In addition symptoms relating to carpel tunnel can come and go without any apparent reason and she had been free from any symptoms for a long time and it would not cross her mind that it could come back.

Although I am aware of pre-existing condition clauses my partner is not. When I asked her if this had been explained to her before she bought the insurance she said it had never been mentioned. The bank made her sign a statement confirming that she had been told of all of the relevant information regarding the policy but how could she possibly know that?

My questions are; Is the insurance company right to reject the claim and if so was the bank at fault in selling the policy without explaining the material clause concerning pre-existing conditions?

The point is that if my partner had known about the pre-existing condition clause and had she realised that past vague pains in the arm would prevent a successful claim for any future medical problem she would obviously not have bought the policy.

Would be grateful for opinions.

ambler

kingstreet

TBH a lot depends on the bank's selling technique/method. What pre-sales documentation does she have? Did she receive an advice and recommendation service based on her circumstances/needs? Does she have an Initial Disclosure Document with the "Key Facts" logo in the top left corner and "About Our Insurance Services" in the top right?

What you describe as income protection is more like payment protection, IMHO, in that it is underwritten at point of claim.

The broker's definition of income protection, permanent health insurance, is fully underwritten at point of sale and she would have disclosed the condition, had it underwritten and the insurer would have excluded it, rated it or accepted it ordinary rates, but she would have known this before committing to the contract.

Given the poor advice and products offered by banks, I'm gobsmacked people still buy such rubbish.

Fool me once, shame on you, fool me twice...

InsideInsurance

I'd also question how long ago it was bought too but it does sound like an ASU or PPI product rather than PHI and so almost certainly is done on a non-advisory basis.

Have you actually read the terms of the policy and its definition of pre-existing? In most cases undiagnosed conditions certainly do still count towards pre-existing however there is often the case that if you have been symptom and treatment free for a defined period of time then it is no longer considered pre-existing.

What does the wording say? When was the last time she went to the docs? When she went and it was diagnosed, what did she say about the frequency of the pain?

It could well be that she has gone to the docs and said she's been having it off and on for years in which case it is pre-existing

ambler

Thank you very much for the above responses. She bought the policy without telling me, I would certainly not have bought such rubbish. I have told her to cancel it but firstly I want to try and get some of her premiums back and I have written to the bank telling them that she was miss-sold the policy.

She was given a Policy Document and a Guide and made to sign a disclaimer saying she has been told the key benefits and exclusions. The Guide says that pre-existing conditions includes anything for which you had symptoms of during the past 12 months.

Before being diagnosed with carpel tunnel six months into the policy she (and I) would have had no idea that having an aching arm a year ago would have constituted pre-existing carpel tunnel syndrome.

I asked the GP and he said that is the interpretation that the insurers have put on his notes. Nobody could say for sure if there was any connection between the two events.

I think that they have a cast iron case but will keep trying.

Thanks once again.

ambler

InsideInsurance

ambler wrote: »

I asked the GP and he said that is the interpretation that the insurers have put on his notes. Nobody could say for sure if there was any connection between the two events.

I think that they have a cast iron case but will keep trying.

It would be good for you to read the report the GP gave to the insurers (though GPs normally charge for this). Generally for ASU/PPI the questions are very straight forward and would be something straight forward like "when did the patient first consult you on this matter?" and "when did the patient advise they first suffered symptoms?"

By the sounds of it your GP has answered honestly and said that you'd had the aching for a year thus it pre-existed the policy.

Whilst it isnt diagnosed it doesnt matter, its when you started having the condition that matters and that is best judged by when they symptoms start. There are some people that wont go to a doctor unless a limb is hanging off but insurers dont want to cover someone who's had terrible gout for years just because they dont like to bother their doctor

OshayAway

It's worth just checking the exact criteria on the T&Cs specific to your policy. The pre-existing conditions time periods do vary on moratorium based applications.

Some are based on treatment, symptoms or consultation 12 months prior to application start date; others 24 months; yet others anything, regardless of how long ago. Typically, these will cease to be excluded 12 or 24 months after treatment, symptoms or consultation.

ambler

Many thanks for the additional responses.

When my partner consulted the doctor with the problem she told him that she had had similar symptoms more than a year ago but these symptoms had disappeared and only returned within the past few weeks. She would not suffer these symptoms for more than 12 months without seeking advice!

The doctor has said that the insurers have chosen to interpret what he has written in her notes in a certain way but that there is no evidence to show that the previous symptoms were Carpel Tunnel Syndrome as they were never medically diagnosed.

His notes are only intended to show that the patient said that they had experienced similar symptoms in the past.

It seems that being allowed to sell these kinds of policies is a licence to print money.

ambler

InsideInsurance

ambler wrote: »

The doctor has said that the insurers have chosen to interpret what he has written in her notes in a certain way but that there is no evidence to show that the previous symptoms were Carpel Tunnel Syndrome as they were never medically diagnosed.

His notes are only intended to show that the patient said that they had experienced similar symptoms in the past.

As said, it would be good to see what he actually wrote.

Lots of doctors are very lazy when doing medical reports despite the massive amount of money they charge for them. The insurers "interpretation" may be 10000% reasonable based on what the GP has written in which case your anger should be at your GP not your Insurers.

In either case, if the GP thinks the rules have incorrectly been applied he should write a letter clarifying the situation which you include with your appeal. Depending on how bad the original note are/ how open they are to interpretation or not then the insurer may accept it or not. The reality is that many GPs have their customers interests more at heart than the insurers and so insurers dont blindly trust GPs especially when the GP says one thing and then in an appeal says the exact opposite.

OshayAway

What InsideInsurance said really ^^^.

Underwriters are in the job of assessing risk based on the evidence presented. Where there is any ambiguity, they will assume the worst case scenario as a protection to cover themselves. Common sense when you think of it that way.

If the GP clarifies their comments, that will shed more light on the specifics and may reverse the decision.

pedro123456

ambler , the IC would have linked a bleeding nose to carpel tunnel syndrome to wriggle out of a settlement, that the nature of the beast I'm afraid :rotfl:

Your other half thought she had bought "peace of mind" to now find out its a pig in a poke........like many insurance products really

Anyway not to digress...........she is entitled to copies of what the GP provided to the IC, these would go some way to explain "how" the IC is trying to evade payment.

So the first thing is for her to ask the GP surgery for a copy of his report. This can be done through the Practice manager, or admin staff.
It would be helpful if she also had a letter from the GP supporting this claim " The doctor has said that the insurers have chosen to interpret what he has written in her notes in a certain way but that there is no evidence to show that the previous symptoms were Carpel Tunnel Syndrome as they were never medically diagnosed"

Consider contacting the IC and ask them to look at her claim again, enclosing further evidence from the GP, if they refuse to reconsider or refuse the claim after reconsidering, ask for their " full and final decision" in writing.

Once you receive their full and final response you can complain to the Ombudsman

http://www.financial-ombudsman.org.uk/

Let FOS decide if she has a case, it costs nothing to try :T