Critical illness payout after stabbing

sarah3891

Hello,

Several years ago my husband was stabbed as he was walking down the street on his way home. The stabbing was an unprovoked, random attack by a man who, high on drugs, was on a rampage, and stabbed six innocent people in one evening as he walked around the streets in our town. Thankfully, my husband survived the attack, despite the knife puncturing his heart and requiring emergency open heart surgery to repair.

At the time, our critical illness policy was underwritten by A company who, as part of their rep selling, claimed open heart surgery, of any type, was a default reason to payout under the CI cover. Following the incident, and a few weeks' after he left hospital, my husband called to make a claim, which he was initially advised, due to the nature of the surgery would be an acceptable one, but shortly after, he was advised it was not a viable claim and basically not to bother. After seveal months of being fobbed off, the stress became a bit too much and he decided to set it aside and focus on recovering emotionally from the incident.

We are now in a position to take up the case once again as he now feels strong enough to tackle this head on, but no real idea how to approach this having been fobbed off before.

The policy definitions make no reference to incidences of this kind and focus very specifically on valve replacements, but the 'sales pitches' of the company reps very clearly stated open heart surgery was a reason for payment.

We appreciate this is a long shot and are just grateful that he survived. However, we do not feel fairly treated by the company in question, which is now under management by another owner, and would like to readdress the issue.

Can anyone offer any advice?

Many thanks xx

tvfreek

Hi,
Sorry to hear what you've gone through. I'm not sure a case against the company is likely however check the policy summary of the Critical Illness policy to see if there were exceptions which relate to your situation.

Words conveyed by a salesman at the time, which do not appear in writing at any point prior to an issue, can't always be relied upon.

antrobus

sarah3891 wrote: »

....The policy definitions make no reference to incidences of this kind ........

That's because it's a critical illness policy. They normally cover the insured against certain specified conditions that are likely to result in death. Getting stabbed isn't an illness, irrespective of whether it kills you are not. You'd need a different sort of insurance for that.

Have you thought about criminal injuries compensation?

tvfreek

emergency open heart surgery may well be a critical illness as defined by the policy summary I previously suggested checking.

antrobus

tvfreek wrote: »

emergency open heart surgery may well be a critical illness as defined by the policy summary I previously suggested checking.

I doubt very much whether any critical illness policy document would cover the insured for injuries suffered as a result of a knife attack. Of course the policy document might say something different, you never know.

P.S. "Open heart surgery" is actually a pretty broad term that covers a wide range of treatments. Critical illness policies may well specify certain things such as arterial grafts or heart valve replacements and suchlike that would fall under that term, but that would be different from the kind of 'open heart surgery' necessary as the result of sharp force trauma. (As they say on CSI.)

tvfreek

Insurance policies are seldom quite so specific as to mention knife attack. However the major exclusion would be for self harm or if the insured did anything, which in the insurer's reasonable opinion, put themselves at risk. I doubt these would apply.

If open heart surgery was covered as a critical illness and developed as a result of the atttack I would like to read the exclusion which prevented the claim as there is none I can think of.

I'd read the definitions very closely...

Insider101

tvfreek wrote: »

Insurance policies are seldom quite so specific as to mention knife attack. However the major exclusion would be for self harm or if the insured did anything, which in the insurer's reasonable opinion, put themselves at risk. I doubt this would apply.

If open heart surgery was covered as a critical illness and developed as a result of the atttack I would like to read the exclusion which prevented the claim as there is none I can think of.

I'd read the definitions very closely...

Not really much more that I can add to this. Whilst the main intention of critical illness cover is to provide against actual illness rather that assault related injuries, the OP needs to check the terms & conditions to see what specifically it says about heart problems

sarah3891

Thanks all. This is really the issue, as we were advised at the time that open heart surgery was covered irrespective of reason, a definition made by many covering parties also, however, the policy definitions document is in clear contradiction to what was claimed by the advisor upon purchase. I work within the Insurance sector (not in personal lines) and this was very clear at the Insurer's seminars, but the claims definitions are in stark contrast to this. I spoke with a rep off the record for the company who was shocked the claim had been denied but of course this is now all semantics......

The company now managing this policy (policy is still in force) clearly states here: http://www.criticalillness.org.uk/bright-grey.html that open heart surgery is covered without further definition, but right now I am unsure if this is a policy endorsement or if it was included in the year in question.....

tvfreek

The salesman may be contradicting the definitions book but not the other way round. In any case, you need specialist advice on this issue.

sarah3891

Thanks.

Any advice on best avenues for most apt. specialist advice? Personal lines is not my area

Thanks very much for all your help x

Paulaviki

I work in insurance too and I've had a look through their list of 'critical illnesses' and I'd say their definitions are clear that for open heart surgery it's only covered to correct a structural defect of the heart.

If you are saying you've been missold the policy, that could be hard to prove because you would have been sent policy documents to review and would have had a cooling off period. Was the policy sold in person or over the phone? If via phone as for copies of calls. But are you honestly saying you wouldn't have taken the policy out unless it covered all forms of open heart surgery?

Ultimately you need to put in a formal complaint to them explaining either why you feel the policy was missold or why the condition should be covered under the policy. They have 8 weeks to provide a response and if you aren't happy with that you can take your complaint to the FOS.