Serous Illness Cover Question

lenaradford

Hello Everyone

I hope you can help me. My husband has been poorly for over 9 months now and he has been diagnosed recently as suffering from Pancytopenia caused possibly by Peripheral Consumption/Destruction, exact cause still unknown.

We have claimed on our Serious Illness cover, but the wording in the policy is ambiguous. It described his condition as Advanced Aplastic Anaamia and the exact wording is as follows;

Aplastic anaemia is the reduction of circulating red
cells, white cells and platelets. For the purposes of
this plan pancytopenia, causing a reduction to 10%
of the normal number of white cells and platelets
as well as 50% of the normal levels of red cells,
must be present. All lines of blood production must
be depressed as demonstrated by bone marrow
examination and abnormalities persisting on blood
tests for a minimum of three months.

My husband fits all the definition and criteria as described in the above statement, however the consultant is unable to confirm Advanced Aplastic Anaemia at this stage because it could be something else, like a very rare form of cancer or bone marrow disease.

I am concentrating on the fact that the wording states that 'for the purposes of this plan, pancytopenia' - well that is exactly his diagnosis so therefore does that mean the plan should payout?

I have sent my eyes square reading and re reading the policy wording, but could just do with some outside opinions.

Do you think we have a chance of a payout?

Many thanks in advance
L xx

InsideInsurance

lenaradford wrote: »

Do you think we have a chance of a payout?

Not yet.

Pancytopenia is basically an observation, all three blood cell types are low.

Aplastic Anemia is a disease that causes pancytopenia but it is not the only one. Your policy appears to explicitly give cover for Aplastic Anemia and not pancytopenia irrespective of cause.

Has he had the bone marrow examination?

If his consultant isnt willing to say its the covered disease yet then its unlikely the policy would payout yet. At the end of the day you have attempted to claim and so may as well see it through to the end as they may take a different interpretation to it than me but I dont think your odds are good until the consultant changes their mind.

Unfortunately these are the limits of Critical Illness policies and one of the reasons I am not keen on them.

lenaradford

He has had 2 bone marrow biopsies so far. And the consultant is not willing to say Aplastic Aneamia as this would suggest a possible Stem Cell/Bone Marrow Transplant being required and at this stage he said it is not the case. He is trying Immune Suppressants first and then will move forward with a diagnosis.

Thank you for your help - looks like we are stuffed financially then