Critical illness claim

michno8

We originally had life and critical illness insurance with bupa. It was later transferred ( sold off)  to the friends life / Aviva group . I've just put in a critical illness claim but it doesnt cover the same criteria that my original bupa policy covered. I didnt know this . Is there anything that I can do about this . Any knowledge or advice would be welcome.   

dunstonh

. It was later transferred ( sold off)  to the friends life / Aviva group . I've just put in a critical illness claim but it doesnt cover the same criteria that my original bupa policy covered.

When an insurance book is sold to a new buyer then the terms of the existing policies remain the same.  Only if you buy a new policy to replace it will the terms change.  So, the coverage should be the same as long as its the same policy you had with Bupa.

michno8

Thankyou . My bupa policy states under paralysis/paraplegia that loss of muscle function or sensation to the whole of any two limbs qualifies.  I am classed as paraplegia through loss of sensation from my waist down but because I have motor movement I cannot qualify as in friends / aviva policy you only qualify if you have complete paralysis of both limbs.is this something I can appeal against . 

Sandtree

dunstonh said:

. It was later transferred ( sold off)  to the friends life / Aviva group . I've just put in a critical illness claim but it doesnt cover the same criteria that my original bupa policy covered.

When an insurance book is sold to a new buyer then the terms of the existing policies remain the same.  Only if you buy a new policy to replace it will the terms change.  So, the coverage should be the same as long as its the same policy you had with Bupa.

The terms will remain the same but interpretation of them or anything that isnt explicit in the terms is subject to change. The Independent Expert opines on these sorts of things and presents their views to the regulators and the court when the former decides if to support the proposal and the later decides if to sanction it. 

OP - presumably you still have your original policy book in which case log a complaint to Aviva and include a photo/photocopy of the relevant term in the book. 

Unfortunately there are practical realities when long term business is transferred between companies... I know when I was involved in one such deal when new wording was introduced in the 90s wasn't abundantly clear (the differences were fairly small) and our system didnt capture the information. The buyer of the policies (just a few years ago) operate in a different way and their systems needed to know which policy wording version was issued... for 99% of customers the right code will have been given but its inevitable that a small number on the cutover time could well have been miscoded. 

michno8

Are assessors medically qualified ? And are telephone calls recorded ?. I received a telephone call stating that my consultant stated that I am able to complete the majority of daily living tasks myself and that he had discharged me and  referred me onto a community OT for further  treatment and rehab . Thus making my claim void. He was quite condescending when I stated an inpatient OT had referred me to the Community OT to assess for adaptations and equipment. Not rehab and treatment.He stated that an OT is a trained medical professional and would not just come to my home to give equipment out. He also made other  statements that my consultants report had supposedly  said . He cannot have realised that I had the report in front of me . The consultant did not refer me for any further rehab . And for 4 out of the 6 daily living tasks he scored me a 2 which equates to significant limitations needing assistance from another person to complete these tasks. Thus fulfilling the criteria of loss of independence. I stated that I would never be discharged from the team due to risk of complications in the future.He jumped on that and stated that while I am still receiving treatments and rehab from them I dont meet the criteria. I am not still receiving treatments or rehab , just open to them for complications that arise from incomplete paraplegia. Is there anything I can do about this .  It seems so wrong and if I didn't have the report in front of me I would have been non the wiser

Sandtree

Never explicitly dealt with critical illness claims handlers but as a former personal injury claims handler and an ex used to be an Accident Sickness and Unemployment handler - none of our teams were explicitly medically trained however we had access to a network of doctors and specialists to refer to if required. 

Calls are normally recorded, they dont have to be but the Financial Ombudsman Service generally doesnt look favourably on companies who cannot produce records of calls that customers complain about.

Your next route is to log an official complaint; if you dont like the outcome of the complaint or they dont respond within 8 weeks you can then escalate to the FOS. Given you had the report in front of you however its a bit of a pitty you didnt call the handler out at the time and ask where in the report it stated the things you are saying it doesnt say. 

Weighty1

michno8 said:

We originally had life and critical illness insurance with bupa. It was later transferred ( sold off)  to the friends life / Aviva group . I've just put in a critical illness claim but it doesnt cover the same criteria that my original bupa policy covered. I didnt know this . Is there anything that I can do about this . Any knowledge or advice would be welcome.   

When did you take this plan out?  I've just looked at a Key Features Document from 2011 and whilst this doesn't give the full clinical definition to meet a claim it does say "total and irreversible".  Based on what you've said it could be that they are querrying whether it is "total" and sometimes for conditions which need to be irreversible it needs to have been present for a certain number of months to significant that recovery is not going to occur.

As has been mentioned, you will still be covered based on the terms of the original plan but typically these have improved over time and not worsened.  For example, now you only need to suffer paralysis of a single limb, not 2, so it'd be surprising if it wasn't advantageous if they assessed you based on modern claims criteria.