Critical illness claim declined

Mumoftwoboys36

Hi,

My husband has been declined a critical illness claim after a discovery of “non-disclosure” and have “avoided” the policy. We are utterly devastated by this news and wondering if anyone has any experience in appealing this. I have been on Financial Ombudsman site to gain advice and i do think we have a good right of appeal. However we are flabbergasted that we are in this position as we believe that the “non-disclosure” was completely innocent due to the wording and our understanding of the questions.

We’ve begun the appeal with the insurance company themselves and now have to wait for their final decision before we can go to the FO

I don’t want to go into too much information on here but I’d like some help and advice of how or who best to go to that could help get our point across, better than us as clearly this is an extremely stressful and emotional situation

Thank you in advance

custardy

Mumoftwoboys36 wrote: »

Hi,

My husband has been declined a critical illness claim after a discovery of “non-disclosure” and have “avoided” the policy. We are utterly devastated by this news and wondering if anyone has any experience in appealing this. I have been on Financial Ombudsman site to gain advice and i do think we have a good right of appeal. However we are flabbergasted that we are in this position as we believe that the “non-disclosure” was completely innocent due to the wording and our understanding of the questions.

We’ve begun the appeal with the insurance company themselves and now have to wait for their final decision before we can go to the FO

I don’t want to go into too much information on here but I’d like some help and advice of how or who best to go to that could help get our point across, better than us as clearly this is an extremely stressful and emotional situation

Thank you in advance

Well it would at least make sense to explain the context of non disclosure.
If you have not disclosed a condition that relates to the claim then theres little point appealing.

Mumoftwoboys36

My husband had 2 episodes of “vertigo” which he saw the GP for one in 2009 and again 6 months later in 2010.

These episodes were when his head was tilted back when in a seated position (dentist chair) and it would spin for a few seconds before resolving. The GP said it was inner ear issue given exercises and no further follow up was required, and he never returned to the GP for this as it didn’t affect him. Which is why it then was forgotten on declaration 2.5yrs later when taking out premium.

on declaration it was asked if ever suffered from dizziness or loss of balance to which we answered no as effectively he didn’t, as he did not have balance or dizziness when standing or moving about. Insurance company have said that if they had known about this then he would not of been offered insurance at all, which I don’t believe to be true.

They want to refund all premiums

BoGoF

He didn't answer the question correctly then. If he answered yes then there would have at least been many questions to be answered before he would be covered (if at all).

What is the critical illness he is claiming for?

Quentin

Whenever you are not happy with your insurance company the route to go down is a complaint in line with their complaints procedure

Then if you are not happy with the reply or they ignore you for 8 weeks you can escalate to the FOS for their adjudication at no cost to you

Mumoftwoboys36

By bogof

Yes we are now aware of this and like I said it was an innocent misunderstanding of non disclosure rather than deliberate and misleading.

And if the we had of answered that question I don’t believe that we would of been declined insurance.

We are making a claim for multiple sclerosis

Mumoftwoboys36

Quentin,

Yes we are in the process of dealing with the complaint team as we had already had a complaint open with them regarding the length of time it has taken to process the claim.

I was hoping that someone could offer advice of who to speak with to help offer advice as clearly we are emotionally exhausted and therefore I don’t want that having an adverse affect on our appeal

dunstonh

The FOS have published guidelines on non-disclosure.

It appears the insurer is following those guidelines. i.e. if it is unintentional non-disclosure the policy should pay out but have any premium difference deducted from it. However, if the insurer would never have offered cover in the first place if it had known about that information, then a refund of premiums should occur.

Only with intentional non-disclosure can premiums be retained.

This is a tough case as clearly there was non-disclosure. And it may well have been accidental. However, it is a condition that the insurer wouldnt have offered cover had they known about it. All you can do is go through the complaints process and hope for a goodwill gesture or a very forgiving adjudicator.

csgohan4

Mumoftwoboys36 wrote: »

My husband had 2 episodes of “vertigo” which he saw the GP for one in 2009 and again 6 months later in 2010.

These episodes were when his head was tilted back when in a seated position (dentist chair) and it would spin for a few seconds before resolving. The GP said it was inner ear issue given exercises and no further follow up was required, and he never returned to the GP for this as it didn’t affect him. Which is why it then was forgotten on declaration 2.5yrs later when taking out premium.

on declaration it was asked if ever suffered from dizziness or loss of balance to which we answered no as effectively he didn’t, as he did not have balance or dizziness when standing or moving about. Insurance company have said that if they had known about this then he would not of been offered insurance at all, which I don’t believe to be true.

They want to refund all premiums

OP you are incorrect, it is not your interpretation of the question but to answer the question in an absolute, had he ever had suffered from X, which the answer should be X not from Y situation.


This is why declare everything and answer everything truthfully. If you are UNSURE, ask as the consequences can be dire which can be in your case.


When i applied for Life insurance, income protection e.t.c, I declared everything, even child hood asthma/Eczema e.t.c no matter how small they can use anything to not claim.


Best bet is to get a full SCR of your patient records which is now free from the new GDPR rules. Then you can go through it wih a fine toothcomb and declare as they won't always request it or request a GP report from your GP.

Weighty1

I'd have been surprised if the insurer would have declined critical illness due to 2 bouts of vertigo in isolation, however, it would be dependent on any other disclosures that WERE made on the application.

For example, if your husband had also disclosed any eye related issue, such as optic neuritis OR something like muscle weakness/tinglings/pins and needles then these can all be indicative of early stage MS so the insurer may have linked them together and declined critical illness on the basis of there being too many symptoms pointing in a certain direction.

Mumoftwoboys36

That’s what they’ve declined us on. We are still awaiting the official letter which details the rationale.

He had no other symptoms ie eye pain weakness etc.

We declared stress and anxiety and other more major declarations on the questionnaire and it was purely those two bouts which they are saying would of made him uninsurable had they known about them. Which I don’t believe to be true given the advice the GP gave and no further investigations needed and he NEVER returned to GP regarding this as it never occurred again