Where is the best place to post about a company policy PHI claim?

Hi,

As the title says, I am having issues with a PHI claim that my employers provide. Where is the best place to post for advice about it please?
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Replies

  • No idea - what is the problem? Since you are here - and the redundancy board would seem like the least obvious place to ask it! - you may as well just carry on and ask the question!
  • sangie595 wrote: »
    No idea - what is the problem? Since you are here - and the redundancy board would seem like the least obvious place to ask it! - you may as well just carry on and ask the question!

    Thank you. I wasn't sure whether to try here or in the Insurance section.

    Basically, I am covered under a policy through my employer. I submitted the application at the end of May. I received a 'decline' on 4/7/16. I submitted an appeal within a few days, which was once again rejected on 7/8/16. I then requested to go through their 'final response' process and this was formally acknowledged and underway on 15/8/16.

    My issue isn't necessarily the outcome, but the time it's taking to sort it out. I never expected it to be accepted in the first place but thought I may as well try. If the claim is eventually accepted, I will only get a small monthly amount anyway, but will also continue with the benefits of employment.

    I am aware that if it is not accepted, I will likely be 'paid off' from my job with a weeks pay for every year worked.

    It is unlikely I will ever return to work (I am on enhanced PIP for both and also support group ESA)..but obviously there is always a small chance it may happen. Based on this, I am not too fussed which way the decision goes, but I am becoming increasingly frustrated at the lack of response. I was advised that the 'final response' was part of their complaints procedure and that they should notify of the outcome within 8 weeks, or provide an explanation as to why they haven't decided and point out the Ombudsman. None of which the have done. I do realise that the policyholder is my company and that means they only have to communicate with them, however it just seems like they're taking the pass. It's now been 10 weeks with only one update and that is only after me requesting it.

    The woman who is dealing with it within the company is completely useless too. She ignores emails. I sent one the other day asking a general question and nothing! She isn't out of the office. She has been like this all the time and I literally have to email 3 or so times before she replies.

    I am just stuck. They say that if they accept the claim then they will be liable from last year (due to absence periods), which also means 'arrears' are building up.

    Is there anything I can do to speed this up? I just hate not knowing where I stand. Am I going to be unemployed for the first time ever? Are they going to pay out?? It's so annoying!
  • I assume I am correct that you are being medically retired and not being made redundant?

    In relation to the company employee, you may be being unrealistic in expecting her to be able to respond immediately. As you say, the company is the policy holder, but that doesn't mean they have the answer for you. They probably have to get the answer from the insurers. And you won't be her whole workload - she will have other work, so chasing this up will not be her only priority.

    But if you are dissatisfied with the performance of the insurer then your options are either to raise that formally with the employer, or go directly to the ombudsman yourself. However, although I appreciate that it says they should respond within eight weeks, I might be inclined to give a little longer - it is only two weeks overdue, especially since you aren't really fussed about the outcome. I appreciate that it may be frustrating for you, but you seem to be having a rough enough time of things with your health anyway, so focussing your energy on fighting with an insurance company may not be the best use of your energy. You will get an answer - the fact you have already had two suggests that they aren't just going to ignore you.


    Out of interest - why have the rejected the claim? Because I am struggling to see how someone who will likely never work again doesn't qualify - but you seem not to be so surprised.
  • edited 28 October 2016 at 6:06AM
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    edited 28 October 2016 at 6:06AM
    sangie595 wrote: »
    I assume I am correct that you are being medically retired and not being made redundant?

    In relation to the company employee, you may be being unrealistic in expecting her to be able to respond immediately. As you say, the company is the policy holder, but that doesn't mean they have the answer for you. They probably have to get the answer from the insurers. And you won't be her whole workload - she will have other work, so chasing this up will not be her only priority.

    But if you are dissatisfied with the performance of the insurer then your options are either to raise that formally with the employer, or go directly to the ombudsman yourself. However, although I appreciate that it says they should respond within eight weeks, I might be inclined to give a little longer - it is only two weeks overdue, especially since you aren't really fussed about the outcome. I appreciate that it may be frustrating for you, but you seem to be having a rough enough time of things with your health anyway, so focussing your energy on fighting with an insurance company may not be the best use of your energy. You will get an answer - the fact you have already had two suggests that they aren't just going to ignore you.


    Out of interest - why have the rejected the claim? Because I am struggling to see how someone who will likely never work again doesn't qualify - but you seem not to be so surprised.

    Thank you for your reply. You are no doubt correct in regard to waiting..I think I just needed to hear it from someone impartial. It is just frustrating. I also have OCD which lends itself to 'wanting to know what is happening' and having things straight in my mind, so that probably doesn't help.

    In regard to the medical retirement..I don't think that is what will happen. I have been off sick, on and off for the best part of 3 years, with my last working day nearly a year ago. I thought I was too young for retirement of any sort (40). I have ME/CFS/Fibro which is generally moderate to severe for me, although I am lucky to be able to do some things. I have been at my company for 13 years and in that time, I have known a few people who have had PHI declined and were just 'let go' on capability grounds, due to ill health.

    In regard to not being surprised - this was just because the people I am aware of applying for it, have all had it rejected. I kind of thought PHI was notoriously difficult to be accepted for from the stories I had heard too, so just didn't get my hopes up, as opposed to thinking I definitely wouldn't get it.

    Their inital reasons for declining were that "I was not suffering a ongoing condition which affects my daily functioning", despite providing medical evidence, consultant letters, clinic letters (occ therapist and pain clinic), all relevant GP notes, meds list, PIP award, statments from people who know me and how they help etc etc!

    They also said "it seemed I was suffering from perceived work related stress"!!:eek: Again, this is despite them having my many occ health reports as well as medical notes confirming my illnesses were NOT work related and were, in fact, ME/CFS/Fibro.

    They also put that my notes showed an "ongoing improvement"..there were not such notes AT ALL - the best my conditions could have been described as would be fluctuating, but more recently a worsening of symptoms, which were reflected in reports and notes.

    And lastly, they said that the notes did not show I was suffering from a mental illness..which, was not actually relevant as far as I can see, because I didn't put it as a reason for being off work - as in I have had OCD and anxiety for years and have worked just fine. However, that is also completely untrue..my notes DO show OCD and anxiety (both I wouldn't have though they could argue were mental illnesses) and the medication I take for them. So, although not relevant as far as I can tell, it is also a lie on their part. It's like they got my notes mixed up with someone elses!!

    Thanks again for your replies.
  • Also, apologies if anything doesn't make sense..it's late and I'm foggy!
  • Don't worry about that - I am currently on so many painkillers that I am either half asleep or away in la-la land!

    OK - I am NOT anything like an expert on PHI because the area that I deal with is employment, and my members have their "PHI" enshrined within their pension plans - so a very different scenario. But the basics have always appeared to be rather similar, although I understand that private PHI insurers are often keen to not pay out. However, if you are up to it, than based on what you have said here I would push this to the utter limits. I'm guessing you aren't in a union or you wouldn't be asking here? So no back up?

    Normally, the get out clause in such policies is that they say that the person is capable of work, just not the work they are currently doing. That does not appear to be the approach here. From what you are saying, their version is that they have ignored your medical professionals and made up their own story! If that is the case, and given that they know that this will be independently reviewed if you go further, then they may be having to reconsider their approach now. The fact is that in most things, people don't appeal. If they do, they give up after losing the appeal. Even when they know they are right AND there is something further they can do. Either it takes too much energy, or they come to believe that it is them that has misunderstood the thing.

    Now please don't take this as being patronising but you are clearly literate and capable. Your language and the clear ordering of your posts tell me that. So make your OCD work for you and just keep going. Yes, do give them a little more time - not too much, but a little. Say, another two weeks. That is reasonable. And then insist on that explanation and the details of the Ombudsman. Leave them in no doubt that you will be taking it further.

    As for the poor woman in the middle - try to make a bit of a friend of her! You can no doubt still recall being chased mercilessly for something that isn't in your control by someone who thinks that you have nothing else to do! I know I get it constantly. Try to acknowledge that you understand she's busy, be nice and not just business like. Try a phone call if you can instead of email - it's easier to be personable by telephone, and we all are open to being misinterpreted just based on written words. If you get the money - or perhaps, even if you don't - a small box of chocolates or a small bunch of flowers might be a nice "sorry I was impatient and I know you tried". Closing gestures that you don't have to make can be so appreciated. It isn't her fault she's caught in the middle.

    Now the employment side - yes, it is entirely reasonable of the employer to let you go on capability grounds now, but they are not likely to do so until they are satisfied that this whole matter is closed, because it has implications for them if they do. They've waited this long, so your just need to make it clear that you will fight any capability process whilst the matter is still open. They won't be paying you now, so it is very little skin off their nose to wait a bit longer. And don't forget all that accrued holiday pay that they also owe you! A bit more holiday pay will be all it costs them, plus the notice pay if that is relevant. I notice that you assume that you will get notice pay - has that been confirmed by the employer?

    Does that help any?
  • sangie595 wrote: »
    Don't worry about that - I am currently on so many painkillers that I am either half asleep or away in la-la land!

    OK - I am NOT anything like an expert on PHI because the area that I deal with is employment, and my members have their "PHI" enshrined within their pension plans - so a very different scenario. But the basics have always appeared to be rather similar, although I understand that private PHI insurers are often keen to not pay out. However, if you are up to it, than based on what you have said here I would push this to the utter limits. I'm guessing you aren't in a union or you wouldn't be asking here? So no back up?

    Normally, the get out clause in such policies is that they say that the person is capable of work, just not the work they are currently doing. That does not appear to be the approach here. From what you are saying, their version is that they have ignored your medical professionals and made up their own story! If that is the case, and given that they know that this will be independently reviewed if you go further, then they may be having to reconsider their approach now. The fact is that in most things, people don't appeal. If they do, they give up after losing the appeal. Even when they know they are right AND there is something further they can do. Either it takes too much energy, or they come to believe that it is them that has misunderstood the thing.

    Now please don't take this as being patronising but you are clearly literate and capable. Your language and the clear ordering of your posts tell me that. So make your OCD work for you and just keep going. Yes, do give them a little more time - not too much, but a little. Say, another two weeks. That is reasonable. And then insist on that explanation and the details of the Ombudsman. Leave them in no doubt that you will be taking it further.

    As for the poor woman in the middle - try to make a bit of a friend of her! You can no doubt still recall being chased mercilessly for something that isn't in your control by someone who thinks that you have nothing else to do! I know I get it constantly. Try to acknowledge that you understand she's busy, be nice and not just business like. Try a phone call if you can instead of email - it's easier to be personable by telephone, and we all are open to being misinterpreted just based on written words. If you get the money - or perhaps, even if you don't - a small box of chocolates or a small bunch of flowers might be a nice "sorry I was impatient and I know you tried". Closing gestures that you don't have to make can be so appreciated. It isn't her fault she's caught in the middle.

    Now the employment side - yes, it is entirely reasonable of the employer to let you go on capability grounds now, but they are not likely to do so until they are satisfied that this whole matter is closed, because it has implications for them if they do. They've waited this long, so your just need to make it clear that you will fight any capability process whilst the matter is still open. They won't be paying you now, so it is very little skin off their nose to wait a bit longer. And don't forget all that accrued holiday pay that they also owe you! A bit more holiday pay will be all it costs them, plus the notice pay if that is relevant. I notice that you assume that you will get notice pay - has that been confirmed by the employer?

    Does that help any?

    Thank you again, that really does help and I do appreciate you replying, particularly when you're in pain!

    I haven't had it confirmed by my employer about notice pay but it is part of my t&c's although, I am not sure how that is affected by the fact I am not getting paid..could the give me my notice and then just 'wait it out', so as not to have to pay me? I know from anecdote that the people I mentioned who have been 'let go', have all been given their notice pay and any accrued hols.

    I am actually in a union but I never even thought of asking them as I didn't think they would be able to intervene with it being insurance related. Not sure why I thought that, but I can't see they can do any more than I have in contacting the lady. And if I do that now, it will probably makes things more strained.

    I could call the lady, it's not an issue - the main reasons I have mailed previously is because a) due to brain fog, I am not always able to 'take in' what I am told and b) because I thought it was best to have a record of all correspondence.

    I will maybe call and ask for an update at the beginning of next week and then give it another couple or so after that before doing anything else.
  • Payment for notice in capability dismissals, if not contractual, is not automatic. Given your length of service, it's probable though. Your union can help with this. And they also have lawyers - to help prepare a case for the ombudsmen. Unions aren't just about getting sacked! We cover anything employment related. So you should speak to them. That is why you have been paying them all those years!
  • sangie595 wrote: »
    Payment for notice in capability dismissals, if not contractual, is not automatic. Given your length of service, it's probable though. Your union can help with this. And they also have lawyers - to help prepare a case for the ombudsmen. Unions aren't just about getting sacked! We cover anything employment related. So you should speak to them. That is why you have been paying them all those years!

    Thanks again. If I am honest, I have never really felt confident in my union reps. There is one lady who works for the union who seems to know her stuff, but is difficult to pin down. Last time I had an issue with work, which was when trying to get a reduction in hours to see if it would help with my illness, I had a union employee representative. He was an employee of my company and a volunteer for the union. However, he was a bit lacking, I found.

    Also, the union have only mentioned their solicitors before in relation to unfair dismissal situations, which this obviously won't be. I am not actually at the end of the company sickness absence procedure either. To be honest, my team leader is notoriously useless at doing anything and after speaking to an employee rep, I was advised that if the process had been done properly, I'd have been long gone! Which I wouldn't have been surprised at.
  • Sometimes lay officials are out of their depth, and should call in the paid staff. If they don't, you should ask. But unless toy are in a very small and unusual union, we can generally instruct on any employment issue if we need to.

    Dismissing someone on capability before the outcome or resolution of employment related terms is often found to be unfair. So the rep is wrong on that. Dismissing you terminates the PHI, and you are not finished with that matter yet. So it would be most unwise of them.
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