Critical Illness benefit definitions

SevenOne

Hello All,

This is my first post here and I was hoping that someone could shine some light on the mysterious subject of critical illness cover.

I have a “Life or earlier critical illness” policy with one of the major UK providers. Earlier this year I got very sick and was admitted to hospital. 2 days later I had heart surgery. The operation went well, but a few months later it was clear that I had not fully recovered. 2 months later I had further heart surgery. This time it was successfully and I made a full recovery. I am very grateful to have this episode behind me, however I was out of work for about 9 months and bills don't pay themselves.

A few months ago my Financial Adviser suggested that I try to claim on my Critical Illness cover, something that had completely slipped my mind (possibly due to more serious concerns). My cover provider does list open heart surgery as a payable benefit condition. However they are very specific about their definition of open heart surgery and list 3 conditions. I meet 2 of the 3 conditions.

I submitted a claim but was rejected on the grounds that I did not meet the 3rd condition. My condition was quite unusual and not one of the more common cardiac surgeries. Both my consultant and surgeon say that I had ‘major’ heart surgery and have cited written examples that contest the provider’s definition of ‘open heart’ surgery.

My question is should I appeal the rejected claim? Are these definitions and conditions contestable? And if so how should I go about this.

I would be very grateful to hear from someone who has knowledge on how these policies work.

InsideInsurance

At the end of the day you have nothing to lose in trying to contest it

That said, I dont think you will be successful. This is the key limitation of CI , it only pays out on a set list of illnesses and only if those illnesses meet a set of criteria. These are set at the beginning of the policy and cannot change at your or the insurers whim.

This is also why I would suggest PHI as a priority over CI as this will payout on any illness irrespective of the markers as long as you are simply too ill to work.

kingstreet

I'm going to guess at no median sternotomy?

The earlier plans required a median sternotomy (division of the breastbone) be required in carrying out the surgery.

Medical advances and the use of Da Vinci robots at places like Papworth and Addenbrooks have seen recovery times from heart surgery drastically shortened.

Many providers have not yet caught up, but the more switched-on insurers have updated their definition to exclude this in later plans.

If I'm wide of the mark, apologies.

clarryd

SevenOne wrote: »

Hello All,

This is my first post here and I was hoping that someone could shine some light on the mysterious subject of critical illness cover.

I have a “Life or earlier critical illness” policy with one of the major UK providers. Earlier this year I got very sick and was admitted to hospital. 2 days later I had heart surgery. The operation went well, but a few months later it was clear that I had not fully recovered. 2 months later I had further heart surgery. This time it was successfully and I made a full recovery. I am very grateful to have this episode behind me, however I was out of work for about 9 months and bills don't pay themselves.

A few months ago my Financial Adviser suggested that I try to claim on my Critical Illness cover, something that had completely slipped my mind (possibly due to more serious concerns). My cover provider does list open heart surgery as a payable benefit condition. However they are very specific about their definition of open heart surgery and list 3 conditions. I meet 2 of the 3 conditions.

I submitted a claim but was rejected on the grounds that I did not meet the 3rd condition. My condition was quite unusual and not one of the more common cardiac surgeries. Both my consultant and surgeon say that I had ‘major’ heart surgery and have cited written examples that contest the provider’s definition of ‘open heart’ surgery.

My question is should I appeal the rejected claim? Are these definitions and conditions contestable? And if so how should I go about this.

I would be very grateful to hear from someone who has knowledge on how these policies work.

I had a similar thing happen to me, but it wasn't my heart. I had a few strokes which where listed on the CI list, but unfortunately like you I tried to claim , they did give me the 1 year's payments which every month I had to prove with a doctor's letter costing me £19 a time that I was still ill but after that I have had to find the money myself for my mortgage and bills. I was of the understanding that if I got really ill ie:stroke etc I would have my house paid off and I could relax and not worry about these things.

Appealing really doesn't get you anywhere because the really do stick to a tight guideline which I don't think they even know at any point.

I would just give them a phone call and ask why they have refused your claim in detail.

SevenOne

@kingstreet, surprisingly close. I did have a sternotomy, twice in fact. However their definition of Open Heart surgery is the use of cardiopulmonary bypass (heart-lung machine).

When I initially phoned about the claim they said that the definition of Open Heart was a sternotomy, division of the breastbone. However they later said that for my policy the definition was cardiopulmonary bypass. Is it possible that their conditions have been updated? The definitions on their website appear less strict and I would probably qualify under (what I think) are under their current conditions.

@InsideInsurance how does one contest these things? Do I contact them myself or should I seek specialist advice; i.e. a lawyer?

kingstreet

SevenOne wrote: »

@kingstreet, surprisingly close. I did have a sternotomy, twice in fact. However their definition of Open Heart surgery is the use of cardiopulmonary bypass (heart-lung machine).

When I initially phoned about the claim they said that the definition of Open Heart was a sternotomy, division of the breastbone. However they later said that for my policy the definition was cardiopulmonary bypass. Is it possible that their conditions have been updated? The definitions on their website appear less strict and I would probably qualify under (what I think) are under their current conditions.

The policy conditions which applied at the time you bought the cover still apply. The insurer can't move the goalposts a few years later.

Do you actually have the written definitions from the point of effecting the cover and do they match what the insurer is saying as I've never comes across this "cardiopulmonary bypass" as a requirement in any heart surgery definition?

InsideInsurance

SevenOne wrote: »

@InsideInsurance how does one contest these things? Do I contact them myself or should I seek specialist advice; i.e. a lawyer?

Given the low chance of success I wouldn't be spending more money on solicitors as its most likely you are simply throwing good money away.

You need to check the policy wording/ definitions in the first instance to ensure what they are excluding it for is indeed required by your policy. As has been said the requirements change over time and wouldnt be the first time someone has made a mistake.

You'd simply register a complaint saying you intend to take the matter to the FOS if you are unhappy with their response and you can take it up to them either after the insurer responds or after 8 weeks, whichever is first.

As I said, unless they've incorrectly stated the terms then you've little to no chance of success as the immutability of the terms during the policy is intended for your protection as much as the insurers but given it costs you nothing to complain some would argue its worth a punt

stephenni1971

Anyone who has a CI policy should periodically have it reviewed as you will find newer policies have some much more beneficial terms now than previously.