Terminal Illness Payout Refused

Bambi89

We took our mortgage insurance when applying for our mortgage with a broker. 6 years in, my 40yr old partner, who was previously fit and well, was diagnosed in September 2022 with stage 3 (of 3) incurable blood cancer. 
With our insurance policy, we have Terminal Illness Cover included. Their only criteria is -
•illness has no known cure or has progressed to the point where it cannot be cured
and 
•in the opinion of the attending consultant the illness is expected to lead to death within 12months

His consultant has written and emailed a letter to confirm that both of these are true, and has also included his staging and advised that treatment has started with the hope of remission/palliative care. 

The insurance company have cancelled the claim and advised that, because treatment has started, he’s no longer eligible to claim? 

Is there anyone that can offer any advice? I’ve been through all of our original documentation and read through all of the terminal illness Ts&Cs but the above is their ONLY criteria! 

We’re between a rock and hard place with this claim and the company are taking no notice.

Any help is gratefully appreciated! 

Thanks!

Clive_Woody

Sorry to hear about your partner. I suspect the reason for the cancellation is that the consultant mentioned treatment with the hope of remission, which may have led the insurers to believe that survival may potentially exceed 12mnths.

I think the consultant needs to be clear if this is just palliative care then he/she should probably not reference treatment with the potential of remission.

DullGreyGuy

If there is hope of remission then the doctor cannot state that they will almost certainly pass within 12 months and hence the decline.  

Bambi89

Hi both, thanks for the advice. 

The consultant had advised in the email 
“Without treatment life expectancy for multiple myeloma with an R-ISS score of 3, would be less than 12 months. ”

Would this not confirm the “12 months or less” criteria?

We’re not eligible to claim anything from anyone. The hospital is 45mins each way and we’re having to go at least once a week, sometimes 2-3 times. 

Our fuel costs per month have rocketed and we’re a family with 2 young children.
Wherever we turn, we get pushed away.  

Thanks again. 

TadleyBaggie

I think the problem here is the "Without treatment..." phrase, if treatment could expand the life expectancy I'm sure that is what is causing the insurance company to withhold the payout.

elsien

Bambi89 said:

Hi both, thanks for the advice. 

The consultant had advised in the email 
“Without treatment life expectancy for multiple myeloma with an R-ISS score of 3, would be less than 12 months. ”

Would this not confirm the “12 months or less” criteria?

We’re not eligible to claim anything from anyone. The hospital is 45mins each way and we’re having to go at least once a week, sometimes 2-3 times. 

Our fuel costs per month have rocketed and we’re a family with 2 young children.
Wherever we turn, we get pushed away.  

Thanks again. 

No. Because he then goes on to say that your husband will be having treatment which changes the prognosis.

He’s effectively said if this isn’t treated then the prognosis is less than 12 months, but they are treating it in the hopes that there will be remission. The implication being that treatment could and might take it out of that 12 months timeline. I agree that that’s the grounds on which the insurer has refused to pay out.

Have you looked into claiming PIP at all? He won’t meet the criteria for the fast tracking but he’s been ill now for three months with the illness unfortunately expected to last so he may well meet the criteria for a claim. 

DullGreyGuy

Bambi89 said:

Hi both, thanks for the advice. 

The consultant had advised in the email 
“Without treatment life expectancy for multiple myeloma with an R-ISS score of 3, would be less than 12 months. ”

Would this not confirm the “12 months or less” criteria?

We’re not eligible to claim anything from anyone. The hospital is 45mins each way and we’re having to go at least once a week, sometimes 2-3 times. 

Our fuel costs per month have rocketed and we’re a family with 2 young children.
Wherever we turn, we get pushed away.  

Thanks again. 

No... without treatment most type 1 diabetics would be dead within 12 months but with treatment they have near normal life expectancy.

The doctor needs to give prognosis with the treatment plan not talk in generality or in a scenario that isnt happening... terminal illness cover is only triggered when there is an appropriate level of certainty that they wont survive the year.