CSI, Unum Provident and Zurich Life

r2strange

This is likely to be a little off topic, so apologies in advance: but I need your help.

Please can anyone who has a "Group Income Protection Policy" with Zurich Life contact their rep to ask about the validity of their policy. Feel free to mention that you have heard of the events below.

Time for a short story...

Back in 1998 I was taken ill with Multiple Sclerosis. This is quite a debilitating condition and I had to give up my job on health grounds. My employer had one of these policies and I began to receive payments under it. Last month I didn't receive any payment, so I phoned Claims Services International Limited (CSI) who are now administering the policy to ask why. I was told that they consider me to meet their definition of medically fit to work full-time (which is complete rubbish) and are terminating my policy. They said a letter would be in the post along with a cheque for two months of payments as a final settlement.

CSI are an off-shoot of Unum Provident, who are a very large insurance company. Having waded through companies house, it seems that Zurich Life have entered into a "re-insurance administration agreement" with CSI for their Group Income Protection Policies. I'm not sure exactly what that means, but I have a hunch it means they don't want to make good on the policies. Out of interest you may like to know that the chairman of both CSI and Unum Provident is a lady called "Susan Ring".

I am currently doing my best efforts to give CSI a kick: i.e. advocacy services, legal advice, and perhaps even the ombudsman ultimately. Hopefully if everyone else who holds a policy can create enough of a stink, it may persuade the companies involved to re-think their ways.

Thank you all for your help in advance.

Matt

dunstonh

i assume you have told them in writing that you disagree and that an appointment was made with an independent doctor who has passed on the medical information for them to reconsider their decision?

r2strange

Thanks for the advice DD. We haven't done that yet, but it is something we may need to do shortly. Following a formal complaint to the Managing Director, CSI have seen fit to grace us with an explanation. Apparently because I have relapsing remitting MS, they consider me fit to work during my remissions. This is in connection with a condition in the policy that says after 12 months of direct payments (not via an employers pay roll) I must be completely unable to work or the policy expires. Having never seen a copy of the policy I am not able to comment as to whether or not there is such a condition. They have invited me to appeal their decision however, and this is now what I will be proceeding to do. Suffice to say I am also attempting to get hold of a copy of the original policy wording.

Interestingly they have made an attempt to sweeten their pay off slightly by adding another month (it now stands at three months).

Matt

Debt_Free_Chick

These policies are very difficult for the individual. The reason being that the contract (policy) is between your employer and the insurance company. Your employer has a blanket (group) policy applying to all its employees, or a defined section of employees.

Your contract is what's stated in your terms & conditions of employment. But that probably just limits what you receive to the amount that your employer gets, under the policy, from the insurance company.

All of this might make any appeal to an ombudsman more difficult. Not trying to deter you from making a complaint, just trying to prepare you for what might be an even more difficult fight.

That said ... check all the paperwork you have from your employer about this scheme. It should explain how the scheme works. In particular, it should specifically define terms such as "illness" or "incapacity" or "disability". These are not the day-to-day terms we would generally expect - they are specifc terms used in the insurance policy and form part of your contract with your employer.

Often, you are required to be permanently incapacitated, in order to satisfy the claim requirements. This is not just at the insistence of the insurance company - this is the policy that your employer wanted. Your employer has defined the type of situations it wants the policy to cover.

Furthermore, you often have to be permanently incapacitated to the extent that you are not capable of any paid work at all. This means that if you could do a different job, then the claim is likely to fail. For example, a phrase used in the industry is "The brain surgeon who can sweep the streets" meaning that if a brain surgeon lost the use of one hand, he might still be capable of other work e.g. he could be a road sweeper. Any claim under the policy would then fail as he is not "permanently incapacitated" to the extent that he is incapable of any paid work".

It is this latter point that the insurance company are disputing, so you need to check the terms of the policy and be clear about the definition of incapacity.

I'm sure no one doubts that you have MS ... the issue is whether you meet the precise definition of incapacity as your employer agreed with the insurance company.

Having waded through companies house, it seems that Zurich Life have entered into a "re-insurance administration agreement" with CSI for their Group Income Protection Policies.

Unum were the first to introduce a "claims management service" for income protection policies. They had a team of qualified nurses/medical practioners whose job it was to check the nature of claims against the definition of incapacity in the policy. They also used to "helpfully" suggest ways that claimants could get back to work. Whether you think this is wriggling out of claims or efficient business, depends on your point of view. You can imagine what Unum's view is ...

Be sure you understand the precise the definition of incapacity, from the policy and any documents issued by your employer. It should help you to pursue your claim. These are notoriously difficult cases to resolve as medical opinion can vary. Some doctors actually suggest that some form of work can be beneficial, to help prevent depression and to give someone who could not otherwise work a sense of "self-worth". Also, doctors have to be honest about their opinions. If they think you could do some work, they are likely to say so.

I am very sympathetic to your situation. My poor old Dad sufferered MS for 17 years and I never knew him other than as disabled.

However, I would like you to be realistic about your chances of succeeding with a complaint - this depends on the policy terms, so check out everything you have from your employer. Once you understand the terms of the policy, you should be in a better position to fight any wrong decisions.

With very best of luck