Critical Illness Claim

Tadpole78

Hi, hope I'm in the right place for a little advice.

A relative has been diagnosed with MS, and basically had her claim under critical illness rejected (even though MS is cited as a critical illness). Basically she had a policy for over 6 years, but in January last year she changed policy (as her mortgage had reduced, she lowered her life insurance cover in line). Then about 6 weeks later she was diagnosed with MS. She since put in a claim, but they have rejected it, on the basis that she had some 'symptoms' prior to her starting her new policy. Yes, 2 years previous she had shingles and a nerve issue, but at the time her GP assured her they were viral, and they did go away within a week or 2, so needless to say, at that stage (or since) there was nothing to make her (or her GP) think that there was anything more sinister underlying. Now, though the insurance company seem to be saying that these were symptoms, and I assume it was a 'pre-existing condition'.

Needless to say, she's distraught, as the prospect of her eventually having to give up work is very real, but she still has a decent mortgage left on her home.
Also, as she has pointed out, if she thought she had MS and would be claiming, why would she have changed policy (and lowered the cover!), but obviously they don't take that on board.

If anyone has any advice it would be much appreciated. Can she appeal etc?

dunstonh

Basically she had a policy for over 6 years, but in January last year she changed policy

This is important as the policy she had for over 6 years would cease and everything relates to the new policy.

Then about 6 weeks later she was diagnosed with MS. She since put in a claim, but they have rejected it, on the basis that she had some 'symptoms' prior to her starting her new policy. Yes, 2 years previous she had shingles and a nerve issue, but at the time her GP assured her they were viral, and they did go away within a week or 2, so needless to say, at that stage (or since) there was nothing to make her (or her GP) think that there was anything more sinister underlying. Now, though the insurance company seem to be saying that these were symptoms, and I assume it was a 'pre-existing condition'.

Technically, they are correct. You have to apply prior to there being symptoms. Otherwise it is a pre-existing condition. However, CIC is underwritten at point of sale. If she had disclosed these symptoms (which she should have) and the diagnosis of the GP (which she should have) and the insurer accepted the application on that correct disclosure then it should not be rejecting the claim. It should only be rejecting it if she did not disclose the symptoms.

Did she disclose the symptoms on the application?

kingstreet

Tadpole78 wrote: »

years previous she had shingles and a nerve issue

I'm with dunston.

If the above was disclosed and the insurer offered terms in full knowledge of them, the decline should be overturned, possibly concluding in a FOS complaint if it isn't.

If they were not disclosed, it's going to be very difficult to get the insurer to change its mind.

However minor something might appear and however a GP might suggest something is routine and unimportant, it should always be disclosed on an application. It's giving the insurer the opening it needs to decline based on non-disclosure.

Weighty1

Whilst the MS may not have been diagnosed prior to the original plan being taken out if there were symptoms being experienced at this point and they were not disclosed then unfortunately your relative is on very shaky ground. Most insurers have a couple of questions which relate to potential MS risks, such as whether there has been any episodes of temporary loss of muscle power, or numbness or persistent tingling or pins and needles. If they had been experiencing these sorts of symptoms before the cover was taken then they should have disclosed them. Had they done this then the provider would probably placed either a postponement on offering cover until any investigations were completed or would have offered the critical illness cover but placed an MS exclusion on the plan.

Tadpole78

Thanks folks.

To be honest, I'm not sure if she disclosed the shingles etc, but I'm meeting her at the weekend so will check, but I'm pretty sure she didn't.

As far as I'm aware she didn't disclose anything, and when she took out the new policy she had no 'existing' conditions. Yes, she'd been to her GP 2 years previous for shingles, but I doubt she even thought to put it on the form, as it was long cleared up...and at that point she never in a million years thought (or even knew) it might be linked to something underlying.
I have to admit, I have my own life insurance about 10 yrs, and I'm pretty sure I didn't disclose everything I'd ever been to my GP about (as I didn't think that was necessary).

Anyway, I'll try and get the finer details, but I'm just trying to do the research etc for her and explain her options, as she was so upset when she got the claim rejection, she can't even really talk about it...and of course the stress of it all isn't helping her condition.

Weighty1

Tadpole78 wrote: »

Thanks folks.

To be honest, I'm not sure if she disclosed the shingles etc, but I'm meeting her at the weekend so will check, but I'm pretty sure she didn't.

As far as I'm aware she didn't disclose anything, and when she took out the new policy she had no 'existing' conditions. Yes, she'd been to her GP 2 years previous for shingles, but I doubt she even thought to put it on the form, as it was long cleared up...and at that point she never in a million years thought (or even knew) it might be linked to something underlying.
I have to admit, I have my own life insurance about 10 yrs, and I'm pretty sure I didn't disclose everything I'd ever been to my GP about (as I didn't think that was necessary).

Anyway, I'll try and get the finer details, but I'm just trying to do the research etc for her and explain her options, as she was so upset when she got the claim rejection, she can't even really talk about it...and of course the stress of it all isn't helping her condition.

It's not that every single thing that you've ever been to the GP about needs disclosing, just that the application questions must be answered completely honestly. You can't presume an insurance company doesn't want to know what a condition or investigation just because a GP has said it's nothing to be concerned about, it needs to be disclosed so that the insurer can then discount it. Underwriters and GP's often look at things in a completely different way.

haras_nosirrah

when she changed cover did she stay with the same insurer?

If she got out a new policy with a new insurer then I can't see an appeal would get anywhere due to non disclosure

If she stayed with the same insurer and just changed cover level then she may be able to appeal as they were on the hook for it anyway and the shingles was after she started cover with them overall

dunstonh

Yes, she'd been to her GP 2 years previous for shingles, but I doubt she even thought to put it on the form, as it was long cleared up...and at that point she never in a million years thought (or even knew) it might be linked to something underlying.

Normally the questions are quite specific. Along the lines of asking if you have ever had certain illnesses but there is a catchall question covering anything in the last 3-5 years. The symptoms and diagnosis would have been captured under that.

mattk_180

As above, it wouldn't have been as specific as "have you had any symptoms for any of the following illnesses.....".


It would have been something more along the lines of "have you had to visit your GP in the past 5 years for any illness". In which case they should have said yes and gave details of what you have mentioned to us, enabling them to amend the terms as necessary and having no reason to reject a claim.

Tadpole78

Just a bit of an update as I was speaking to my relative at the weekend.


The policy is with the same provider as her previous one. But it gets even messier. She changed the policy via a broker (financial advisor I think), who she went to see about her mortgage rate. He then said that she could reduce her life insurance premium, which she agreed to. He then went ahead and did everything pretty much. She is adamant she didn't fill in a form or even sign a form. The broker rang her a few days after the conversation asking "if she'd been sick recently" to which she replied no.


When she then contacted the broker to say she had been diagnosed with MS and would be making a claim he replied "well you look ok to me" and then hung up on her. You couldn't make it up. He eventually rang back to apologise but said she'd be very lucky if they paid out (or words to that effect). Is it just me, or does that all sound a bit dodgy from the broker? She's beyond stressed at the minute by it all, and still hasn't done anything about appealing etc, as even thinking about it all upsets her. Any advice much appreciated.