Critical Illness Advice Needed Desperately :(

ladylea13

Help/ advice needed desperately......
Me and my husband currently have a mortgage with Halifax and on that mortgage we took out Life Insurance & Critical Illness which we have been paying this since we took the mortgage out 5 years ago.
In January my husband was diagnosed with skin cancer (Malignant Melanoma) and has so far had to have 2 different moles removed as well as having to have them re-excision. The specialist nurse we see made us aware that if we have a mortgage and have critical illness on it we will be covered (we wouldn't of even though about looking into this had she not mentioned anything). So we went home and dug out the paperwork and started the process of the claim. They obtained the Consultant & GP Records.
My husband called them for an update as we had not heard anything for a while, the lady he was speaking advised that they had sent some correspondence to us as they require further information, at which my husband asked her what was the information they required, to which she replied by asking him when was the last time he had a cigarette?? We could not understand why this information was relevant as we disclosed that we are smokers.
I have dug out all the paperwork and when we was first quoted for this cover they had us down as non-smokers (the premium was quoted at £70.00 pm), at which we had it promptly amended and received correspondence showing the revised policy with the correct details (The premium was then increased to £90.00 pm which is what we have been paying all this time). We wrote to them at the end of March advising that we could not understand why they are requesting to know when he stopped smoking, we also enclosed our policy which shows we are smokers. SO....we didn't hear anything from them for a few weeks so my husband called them and asked what was happening, they acknowledged receipt of our correspondence and informed him that the policy was amended to show that we was non smokers (even though we have continued to pay the premium of £90 pm) however they did not disclose to him who amended this and that they would be writing to us (neither i nor my husband would have done this) It has now been over a month and a half and after umpteen phone calls chasing them for this "correspondence" we still haven't received (Even though when my husband called last week the assured us that we would have it by the 14th of this month....still nothing)
So...if there is anyone that can advise me on where to go from here or give me any advise (is it worth while getting a solicitor involved?? if we do will we be responsible for the legal costs) i would gratefully appreciate it because we really are at the point of giving up

Better_Days

Sorry to hear your husband is so poorly.

Don't give up on the CI. I have experience of claiming on a critical illness policy and it was not pleasant. Insurers try and grind you down by being awkward and obstructive. Also be aware they they may try and actively mislead you during telephone conversations. Carry out all correspondence in writing.

Check the complaints proceedure for your insurer.

But before that your husband may wish to consider making an application under the DPA to get a copy of the paperwork relating to his policy and the related computer records. You may find it very useful in identifying exactly what has happened. Don't send any original paperwork off to the insurer if it strengthens your claim - they could well 'lose' it.

Also check the policy booklet very carefully to see if your husband is covered by the policy. Be aware that your insurer will probably want your husband to be examined by their 'expert' who could disagree with the diagnosis, treatment and prognosis irrespective of the opinion of your husbands medical team.

If you feel your husband has been treated unfairly you will need to go through your insurers complaints proceedure. If you remain unhappy then you can go to the Financial Ombudsman Service.

In my experience, and in that of a friend who went through a CI claim, insurers will do anything to wiggle out of paying out. I hope you get this sorted out as this is the very time when you do not need the hassle, but you also need to be aware of the path that this may take.

longtimelurkersam

Ok first things first, hope he makes a sufficiently speedy recovery and well done to the specialist nurse, so many people don’t realise they have the cover so I am glad to see the medical professionals asking about it. When you get this settled in your favour send her some chocolates or something.

Malignant Melanomas are one of the easy ones to deal with when assessing claims. Diagnosis is straightforward on biopsy and the diagnosis is unlikely to be questioned by the insurer, particularly if two MM’s have been removed and classified accordingly. Your husband’s treatment and prognosis is of no interest to the insurer, all they want to know is does he have the right type of cancer that fulfils the policy criteria. I suspect the answer to that is yes and the delays are being caused by the smoking status/admin issue.

£90pm depending on your ages and medical history could have given you a level of cover that might mean the actual decision is out of the insurers hands and is in the hands or its reinsurers (companies that insure the insurer!), hence the delay as everything needs to be received by Halifax, assessed, sent to the reinsurers who assess it in accordance with their expert medical team if required, then a decision provided to Halifax, who receive it, it waits for a few days to get processed then someone at Halifax assess it and then has to get sign off internally and then they communicate to you…….….repeat for all the bits of information that are required. Sometimes the insurer and reinsurer do not agree and they get into a battle and this is what could be happening here. Insurer made mistake in admin and reinsurer not prepared to pay their share of the claim.

As Better Days says. Get in a Data Protection Act request NOW. This will get you their file including UW papers and notes about the claim so you will have all the information to hand. You will then have your file and will be able to compare.

In addition phone up and make a complaint to get that in the system and underway. What I can tell you is that if there is any doubt as to what happened, ie you have a document from them saying you are declared smokers but they didn’t action it properly the Financial Ombsudsman Service (FOS) will come down on the side of the customer, ie you. It doesn’t matter whether your smoking status changed during the term of the policy (unless you requested an increase or amendment to the rates to reflect now a non smoker) what matters is whether you answered the proposal question truthfully at the time.

I spent a lot of years assessing these claims and generally the assessors have a good skill set are well trained and are not employed to “catch you out” or “find ways to turn claims down”. Everyone has their own opinion and that is mine.

Better_Days

longtimelurkersam wrote: »

I spent a lot of years assessing these claims and generally the assessors have a good skill set are well trained and are not employed to “catch you out” or “find ways to turn claims down”. Everyone has their own opinion and that is mine.

I think the experience of claimants may depend partly on diagnosis. And in OP's case it maybe fairly straightforward. However, in my case despite having medical evidence from 3 specialist consultants confirming diagnosis and prognosis my insurer did try to 'catch me out'. They sent out a psychiatrist to 'assess' me who had no specialist knowledge of my illness (he said I was a hypochondriac - for following the advice given to me by my NHS consultant). The insurers also put me under surveillance. I obtained a copy of the report under the DPA and discovered that the people they employed to check me out were using binoculars to see into our living room. My solicitor said that he had come accross cases where insurers went through claimants rubbish and used infra-red cameras to see through curtains/blinds.

At every stage the insurer was obstructive and awkward. They refused to tell me what in their opinion my diagnosis was, yet insisted they were refusing my claim because I had not had 'optimal treatment'. This was despite medical evidence, from 3 specialist consultants, to the contrary. They refused to tell me what medical evidence they would accept. They said that because I had paid for 2 consultants reports, those opinions lacked validity. They did not apply the same criteria to the medical report that they paid for.

This dragged on for years and my health deteriorated further. In the end I employed a solicitor and within a couple of months the insurer paid up. They refused my claim for as long as they thought they could get away with it. Disgraceful.

OP, I do hope that you get this sorted out quickly.

longtimelurkersam

Better_Days wrote: »

I think the experience of claimants may depend partly on diagnosis. And in OP's case it maybe fairly straightforward. However, in my case despite having medical evidence from 3 specialist consultants confirming diagnosis and prognosis my insurer did try to 'catch me out'. They sent out a psychiatrist to 'assess' me who had no specialist knowledge of my illness (he said I was a hypochondriac - for following the advice given to me by my NHS consultant). The insurers also put me under surveillance. I obtained a copy of the report under the DPA and discovered that the people they employed to check me out were using binoculars to see into our living room. My solicitor said that he had come accross cases where insurers went through claimants rubbish and used infra-red cameras to see through curtains/blinds.

At every stage the insurer was obstructive and awkward. They refused to tell me what in their opinion my diagnosis was, yet insisted they were refusing my claim because I had not had 'optimal treatment'. This was despite medical evidence, from 3 specialist consultants, to the contrary. They refused to tell me what medical evidence they would accept. They said that because I had paid for 2 consultants reports, those opinions lacked validity. They did not apply the same criteria to the medical report that they paid for.

This dragged on for years and my health deteriorated further. In the end I employed a solicitor and within a couple of months the insurer paid up. They refused my claim for as long as they thought they could get away with it. Disgraceful.

OP, I do hope that you get this sorted out quickly.

Lucky guess but i suspect you were claiming for CFS/ME under the TPD/PTD element of the policy.

Better_Days

Ahh... so the experience of claimants does depend on the diagnosis.

No mention in the glossy brochures and slick promises that if the claimant is unlucky enough to be diagnosed with an illness that the insurer doesn't like then they will be given a very rough ride.

OP - if you are still following the thread and you do decide to make a DPA application here is a useful page on the ICO website which even gives a suggested format for a letter
http://www.ico.org.uk/for_the_public/personal_information

When the info is disclosed do look at it with a critical eye and go back to the insurer if you think anything is missing. In my case I went back to them and twice they responded with 'whoops - we forgot to send you this'

Hope it goes well for you both.

ladylea13

Sooooooo....still in the same position we was in at the beginning of the year..we decided in the end that this was to much for us to continue on our own with as all we was getting was correspondence stating "why haven't you replied to our correspondence dated such and such" even though we had never received such said correspondence. We have now had our solicitor involved since July and we are still no further forward (he has also only ever received the "why haven't you responded to our correspondence dated such & such" even though the solicitor has never received such said correspondence ....we are really now at a loss as to where we go from here (Our solicitor cannot believe that we have not even had a denial letter)... all of this is causing great stress and uncertainty....can anyone please suggest or help any further :-(

Cazza

Did you follow the insurer's formal complaint process and then take everything to the FOS, before going to the solicitor?

ladylea13

No...we tried corresponding with them and then their correspondence stopped all together,which is when we got the solicitor involved (i am out of my depth with all of this which is why we got the solicitor involved as it was just getting to stressful, i was hoping that by having a legal person represent us that they would correspond, however this has not happened)

Cazza

You need to "formally" complain to the insurer, then take your complaint to the FOS if you're not happy. Guidance here...

http://www.financial-ombudsman.org.uk/consumer/complaints.htm

ladylea13

Thank you so much :-)