Critical illness payout after stabbing

sarah3891

Paulaviki wrote: »

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.

No, but I am saying we were explicitly told it covered open heart surgery of any type. Our IFA at the time also was advised the same and as a result of our fob off he refused to sell their products any further and took this issue up with them independently having sold the same policies to others. This was both on the telephone and face to face at a seminar. They however denied having a telephone recording of the sales call, and we have that statement (the denial) in writing.

Taking your wording onboard 'structural defect of the heart', this would be the case with a stab wound as the wall of the heart was punctured. Also if you are referring to the Brightgrey wording, this merely states 'open heart surgery' where the sternum has been opened.

As before, we appreciate based on the black and white facts, this is all very unlikely, but either way my husband feels he wants to at least escalate this further so I am just trying to determine next best action.

Thanks x

Paulaviki

sarah3891 wrote: »

No, but I am saying we were explicitly told it covered open heart surgery of any type. Our IFA at the time also was advised the same and as a result of our fob off he refused to sell their products any further and took this issue up with them independently having sold the same policies to others. This was both on the telephone and face to face at a seminar. They however denied having a telephone recording of the sales call, and we have that statement (the denial) in writing.

Taking your wording onboard 'structural defect of the heart', this would be the case with a stab wound as the wall of the heart was punctured. Also if you are referring to the Brightgrey wording, this merely states 'open heart surgery' where the sternum has been opened.

As before, we appreciate based on the black and white facts, this is all very unlikely, but either way my husband feels he wants to at least escalate this further so I am just trying to determine next best action.

Thanks x

If they don't have a recording of the call then that could go in your favour as they can't disprove they didn't missell the policy. So you could pursue that? Remember it costs them £550 per FOS case so they might make a gesture payment under that amount to try and stop you taking it further.

The structural defect bit comes from their document which gives definitions of all the critical illnesses they cover which is here http://www.brightgrey.co.uk/why-choose-bright-grey/our-booklets/#doc-illnesses-you-cover

They don't seem to specify what they mean by structural defect, but this is the medical definition, and doesn't mention defects due to injury. http://www.ucl.ac.uk/cardiovascular/research/structural-heart-disease

But again if you feel their definition is open to interpretation then definitely get that formal complaint in asap and get the 8 weeks started.