Advice on Total Permanent Disability Claim

gumballwatterson

Hello all,

I've begun a claim on a joint critical illness policy, being made under the Total Permanent Disability clause, and being required to meet the following criteria (exact wording);

Bending - You are unable to bend or kneel as if to pick up a weight of 1kg from the floor, and straighten up again without the assistance of another person.

Walking - You cannot walk a distance of more than 200 metres on flat ground without stopping.

Lifting and Carrying - You cannot pick up from table height and carry for 5 metres a 2kg weight with either hand. Either hand means both hands have to fail the test separately in order to satisfy this activity.

Standing - You are unable to stand, with the aid of a walking stick if necessary, for more than 10 minutes before needing to sit.

I personally find these descriptions extremely vague and open to interpretation, and I'm not sure what to expect next in terms of the insurance company's actions. Having been through the process of obtaining PIP I'm feeling very cynical about the whole thing!

I'm looking for any advice on how to make the case run as smoothly as possible, and also of any pitfalls/gotchas I should be aware of.

Thanks in advance!

csgohan4

The best thing is to be honest and open as the insurers will likely get a physical examination of you as well and under certain circumstances covert filming before/after the award

Weighty1

Your policy has been arranged with Total & Permanent Disability being on an Activities of Daily Living definition basis. This can be for various reasons, however, it does mean the ability to claim for a TPD is extremely difficult.

I don't think the wording is vague. It states exactly what you must be unable to do to validate a claim.

HOWEVER, ordinarily there is a list of 6-8 activities and you must be expected to be TOTALLY unable to do either 3-4 of them EVER AGAIN to be able to make a claim.

gumballwatterson

csgohan4 wrote: »

The best thing is to be honest and open as the insurers will likely get a physical examination of you as well and under certain circumstances covert filming before/after the award

Thank you csgohan, that's the plan! Yes, a physical examination was fully expected so thank you for confirming this may be the case.

gumballwatterson

Weighty1 wrote: »

Your policy has been arranged with Total & Permanent Disability being on an Activities of Daily Living definition basis. This can be for various reasons, however, it does mean the ability to claim for a TPD is extremely difficult.

I don't think the wording is vague. It states exactly what you must be unable to do to validate a claim.

HOWEVER, ordinarily there is a list of 6-8 activities and you must be expected to be TOTALLY unable to do either 3-4 of them EVER AGAIN to be able to make a claim.

Thanks for your response Weighty.
Yes, there are another couple of activities in the policy that we (the claimant is my spouse) feel that they are able to do okay. The reason why I think the wording is vague is the walking activity for example;

Walking - You cannot walk a distance of more than 200 metres on flat ground without stopping.

What is the thing that is meant to stop the claimant from walking? If it was a physical problem then judging this could be more straightforward, but I can see a neurological (intense pain which is largely governed by an individuals threshold) problem being difficult to prove or disprove.

There will be a number of years worth of medical evidence to support this claim too, so it seems unjust that it may all come down to one person's view. Or maybe this isn't the case?

Nearlyold

Sorry to hear of your spouse's illness. Do you have a confirmed medical diagnosis of the condition that your spouse is suffering from and does this diagnosis confirm that the current disability is one where recovery is unlikely. As Weighty1 says the disability must be permanent.

If the condition is one where, for example, Cognitive Behaviour Therapy has been known to be efficacious there may be more difficulty in making a successful claim.

gumballwatterson

Do you have a confirmed medical diagnosis of the condition that your spouse is suffering from and does this diagnosis confirm that the current disability is one where recovery is unlikely.

There is a confirmed diagnosis of Degenerative Disc Disease although this does not appear to be the sole problem, as a lumbar fusion operation has been been unsuccessful in addressing the symptoms. Due to the nature of the condition it has been difficult to obtain any kind of diagnosis from anyone so far.

If the condition is one where, for example, Cognitive Behaviour Therapy has been known to be efficacious there may be more difficulty in making a successful claim.

Yes I agree on your point. CBT and a long period of physiotherapy were prescribed to help manage the pain and recovery, but this has also been unsuccessful. I understand that such treatments can be seen as subjective.

In your opinion is it possible that things would be looked at differently knowing that actual surgery has taken place?

Nearlyold

A confirmed diagnosis of a definite physical cause of the disability with consultants reports plus presumably CT scans etc. will certainly help in establishing the bona fides of the claim.

I asked because I wondered if your spouse had ME/CFS (which doesn't have a readily identifiable physical cause) as you only mentioned the pain aspect previously.