Critical illness claim; consultant won't send in paperwork

BooJewels

ripplyuk wrote: »

Hopefully your insurer has enough info but either way, I’d make a complaint to the GMC about this consultant. His refusal has caused stress at an already difficult time.

It has indeed. We've just been bereaved too, so could do with a turn in fortunes. I'm going to hold this in reserve for the time being - to revisit later. We still have to have a working relationship with this doctor and I need to let the claim run its course for the moment. As it's my husband's care, ultimately he will decide how to proceed in this respect. But he did say that he wasn't going to let this one rest - if not for his sake, but for those that follow. Sometimes you have to take a stand to improve things for others.

The insurers were supposed to ring me yesterday to discuss alternative ways of getting the information to them that they need. But as they haven't yet, I'm hoping this is because they've decided that they've got enough already. It's possible, looking at dates, that the GP has already sent the more technical letter I just realised that I have, as they sent a package off a couple of days after we got our copy.

danceinthedark

When you speak to the insurer, try to specifically ask the question !!!8216; Have you been able to confirm that the policy definition has been met? !!!8216; because in all honesty, they should know for definite if they have enough from the GP. Having a copy of the initial biopsy results, or a consultant letter to that effect, is often the minimum requirement to confirm the diagnosis meets the policy definition for cancer (although there are some exceptions to this, including !!!8216;new!!!8217; definitions of prostate cancer). Although they may have only approached the GP initially for info about his medical history and not the diagnosis, they should be on the ball enough to identify information that also can be used to confirm the diagnosis, particularly when they know the consultant is not forthcoming.

Do let us know how you get on - it may be that they have to obtain internal sign-off on a decision if its outside their usual evidential requirements, which could explain the delay in calling you

BooJewels

danceinthedark wrote: »

When you speak to the insurer, try to specifically ask the question 'Have you been able to confirm that the policy definition has been met?'

Thanks for that, I'll note that to ask next time we speak. There is a question in the form to the GP that details the cancer definitions and asks if the GP believes the definition has been met and he's answered 'yes' (i.e some cancers in situ and pre-cancers aren't covered etc.). We also heard a little while ago that the underwriters had passed the condition he's claimed for as one they cover.

So we can only assume from that point that they wanted confirmation that he definitely had a firm diagnosis of that condition. I think they've had several pieces of material that confirm the diagnosis, from us and from the GP - including copies of the consultant's letters. But when the consultant first voiced reluctance, we rang and asked if we could manage without his report or provide alternative materials and after a while on wait, the underwriters apparently said they couldn't proceed further without it. I think their view has softened on this in the last week after receipt of more materials from the GP after they questioned what they thought was a pre-existing condition mentioned in a 6 year old letter - which was a mistake and the GP has clarified.

Although they may have only approached the GP initially for info about his medical history and not the diagnosis,

The initial GP form was quite brief, but did ask some rudimentary medical history questions about how long he'd been a patient and about smoking and alcohol consumption and also asked, as mentioned, if the diagnosis met their cancer criteria and for a brief description of the current diagnosis - he explained and enclosed all of the consultant's 25 previous letters.

they should be on the ball enough to identify information that also can be used to confirm the diagnosis, particularly when they know the consultant is not forthcoming.

I think this is where we're at now, realising that the consultant may never provide answers directly, but they do have a lot of information from him indirectly already.

Do let us know how you get on

I will do, thanks for the help. I've been searching myself to try and find information on people with similar claims/medical conditions etc. and found little, so it might help someone else reading too.

BooJewels

I meant to add; we also had a secondary claim approved for a credit card with the same company - we found by accident that the PPI on it included critical illness and they've already settled this by paying the entire balance on the card, so they must be reasonably happy that he met the diagnostic criteria. We hoped at the time that it was a good omen.

Although I would imagine there must be a point where it costs more to investigate than the value of the claim and unfortunately (as it were, for us) it wasn't a card we used much and didn't have much of a balance, so they will presumably have settled that without needing anything like as much confirmation as the significantly bigger lump sum mortgage payout.

But you'd think that he either meets the policy requirements or he doesn't.

BooJewels

Just to post an update: I finally got the call back, but it seems to have been a spectacular case of crossed wires, causing a waste of time for all parties. This supervisor wasn't ringing to answer what would happen if we didn't get the report from the consultant and how else we might get that data, or if indeed we already had enough to make a decision. She was ringing because it was recorded that I'd lodged a complaint about how long it was taking and demanded to speak to a supervisor. That couldn't possibly be further from the truth.

In fact the lady I spoke to last week apologised for now long it was taking and I actually said that she had no need to apologise at all as she wasn't the one causing the problem and told her how everyone at the insurers had been kind and patient with us and were about the only party involved that I wasn't unhappy with. I'm actually mortified that my comments have been recorded as a complaint in any way - it truly, truly wasn't. I explained all this and she said it was likely that customer care would follow up on it, so I could explain to them. She had no idea about the answers to the questions I'd actually asked as it wasn't her department. We've now had an additional week of pointless tension.

The good news is that the consultant has now sent in his report after all and they got it this morning. I think our specialist nurse (funded by Macmillan) applied pressure and helped him complete it and then posted it off. It will go to the underwriters with everything else to make a decision. We're all hopeful now that they have all they need and there won't be any further delays.

BooJewels

I'm delighted to update the thread with the news that the claim has now been settled, which enabled my husband to make the choice about the next stage of his treatment today and set that ball rolling.

He knew today was an important one in the decision making process and the underwriters made the final decision just in time for us. We'd hardly dared to spend too much time thinking about it until we knew the financial outcome. It's unfortunate really that you have to make medical treatment decisions on the basis of whether you can afford the time off work etc. - I know from conversations I overheard in the unit today that he's far from alone in that. It's been hard for him to date to work through treatment, but that won't be at all possible with the next process.

But making decisions is quite liberating in itself; you can then just concentrate on what needs to be done on a day by day basis.

Thanks for your support and help, it's truly been appreciated. :beer:

danceinthedark

Very pleased to hear its all sorted now

Wishing your husband well with his treatment and recovery

BooJewels

Thank you, so are we. Thanks for your help.

danceinthedark wrote: »

Wishing your husband well with his treatment and recovery

Thank you, I'll pass it on. There is no cure, but he's responded as well as could be hoped to treatment, so this opens doors for a further treatment that will hopefully buy him some remission time. We're hoping that his good response continues.