Critical illness claim rejected

JLJ11

Hi,

I'm pretty new to forums but have been trying to read up on loads about this too. 

I was diagnosed in Dec 2023 and have critical illness cover with my employer (high street bank) and was told as I have had cover for over a decade that MS was on the list to claim for.  They have rejected my claim as my GP history and through the diagnosis letter stated that I had an MRI in 2009 which was all clear and no further action was needed but consultant who diagnosed me with MS feels that may have been the starting point. 

The clause was that I had previous symptoms whether diagnosed or not means claim can't be paid out. I have raised a complaint (not sure whether pointless) but feel that how could I of know that this would have been MS when the consultant and GP at the time had no concerns?

I'm struggling on what to do next as I feel that it was an easy way out as all this was out of my control. With the policy through work there is no questionnaire to state any illnesses previously that should be noted.

Any advice

Thanks!

DullGreyGuy

Why did you have the MRI in 2009?  Was it for undiagnosed symptoms that could be early stages of MS or something totally unrelated like a head injury?

What was the outcome after? No diagnosis and you just lived with the symptoms? The symptoms disappeared of their own accord? Got given some other diagnosis and treatment?

Weighty1

Sorry to hear about your diagnosis.

Where the symptoms you were experiencing asked about on the application for the insurance?  Many applications now ask about neurological symptoms, such as persistent pins and needles, loss of muscle power, balance problems, even if no diagnosis has been made.

Also, if they were asked about had they occured within the timeframe that they are asked about.  The above symptoms are normally asked about in the last 4-5 years.

Which insurer has declined the claim?  One thing to consider is the nuances of how the question is asked.  For example, L&G ask if you've seen a doctor, nurse or other medical professional, so symptoms within that timeframe don't need mentioning if they've not required you to see a doctor/nurse etc within that timeframe.

JLJ11

DullGreyGuy said:

Why did you have the MRI in 2009?  Was it for undiagnosed symptoms that could be early stages of MS or something totally unrelated like a head injury?

What was the outcome after? No diagnosis and you just lived with the symptoms? The symptoms disappeared of their own accord? Got given some other diagnosis and treatment?

I had numb sensation on arm and face. The MRI was clear and they discharged me. The dr at the time say I needed to stop smoking and was referring me to an obesity clinic as I was overweight at the time but no mention of what they though it could have been. My symptoms disappeared a couple of weeks later as stated on medical report. No treatment given and no follow up 

JLJ11

Weighty1 said:

Sorry to hear about your diagnosis.

Where the symptoms you were experiencing asked about on the application for the insurance?  Many applications now ask about neurological symptoms, such as persistent pins and needles, loss of muscle power, balance problems, even if no diagnosis has been made.

Also, if they were asked about had they occured within the timeframe that they are asked about.  The above symptoms are normally asked about in the last 4-5 years.

Which insurer has declined the claim?  One thing to consider is the nuances of how the question is asked.  For example, L&G ask if you've seen a doctor, nurse or other medical professional, so symptoms within that timeframe don't need mentioning if they've not required you to see a doctor/nurse etc within that timeframe.

There was no application as it was a benefit I signed up for with work. Symptoms I experienced before was 15 years ago 😢 but they advised that as the clause states I had 'symptoms whether diagnosed or not ' that's why they won't pay out claim.

HSBC declined claim

Weighty1

JLJ11 said:

Weighty1 said:

Sorry to hear about your diagnosis.

Where the symptoms you were experiencing asked about on the application for the insurance?  Many applications now ask about neurological symptoms, such as persistent pins and needles, loss of muscle power, balance problems, even if no diagnosis has been made.

Also, if they were asked about had they occured within the timeframe that they are asked about.  The above symptoms are normally asked about in the last 4-5 years.

Which insurer has declined the claim?  One thing to consider is the nuances of how the question is asked.  For example, L&G ask if you've seen a doctor, nurse or other medical professional, so symptoms within that timeframe don't need mentioning if they've not required you to see a doctor/nurse etc within that timeframe.

There was no application as it was a benefit I signed up for with work. Symptoms I experienced before was 15 years ago 😢 but they advised that as the clause states I had 'symptoms whether diagnosed or not ' that's why they won't pay out claim.

HSBC declined claim

Ah ok, so it was a claim under a Group Critical Illness Policy.  That definitely makes it more difficult as they do have these pre-existing condition clauses written into them.  That said, it appears a bit contrary to acting in good faith that the symptoms were 15-years prior to the claim and so could potentially usee these clauses if someone has ANY sort of symptom within their life.  If this was me, I'd probably complain to HSBC on this basis and then if that was declined I'd contact the Financial Ombudsman Service and refer it to them.

Good luck.

BarelySentientAI

Weighty1 said:

JLJ11 said:

Weighty1 said:

Sorry to hear about your diagnosis.

Where the symptoms you were experiencing asked about on the application for the insurance?  Many applications now ask about neurological symptoms, such as persistent pins and needles, loss of muscle power, balance problems, even if no diagnosis has been made.

Also, if they were asked about had they occured within the timeframe that they are asked about.  The above symptoms are normally asked about in the last 4-5 years.

Which insurer has declined the claim?  One thing to consider is the nuances of how the question is asked.  For example, L&G ask if you've seen a doctor, nurse or other medical professional, so symptoms within that timeframe don't need mentioning if they've not required you to see a doctor/nurse etc within that timeframe.

There was no application as it was a benefit I signed up for with work. Symptoms I experienced before was 15 years ago 😢 but they advised that as the clause states I had 'symptoms whether diagnosed or not ' that's why they won't pay out claim.

HSBC declined claim

Ah ok, so it was a claim under a Group Critical Illness Policy.  That definitely makes it more difficult as they do have these pre-existing condition clauses written into them.  That said, it appears a bit contrary to acting in good faith that the symptoms were 15-years prior to the claim and so could potentially usee these clauses if someone has ANY sort of symptom within their life.  If this was me, I'd probably complain to HSBC on this basis and then if that was declined I'd contact the Financial Ombudsman Service and refer it to them.

Good luck.

It does appear that at least in this case the symptoms were plausibly related to the later condition, even if not diagnosed at the time.

Weighty1

BarelySentientAI said:

Weighty1 said:

JLJ11 said:

Weighty1 said:

Sorry to hear about your diagnosis.

Where the symptoms you were experiencing asked about on the application for the insurance?  Many applications now ask about neurological symptoms, such as persistent pins and needles, loss of muscle power, balance problems, even if no diagnosis has been made.

Also, if they were asked about had they occured within the timeframe that they are asked about.  The above symptoms are normally asked about in the last 4-5 years.

Which insurer has declined the claim?  One thing to consider is the nuances of how the question is asked.  For example, L&G ask if you've seen a doctor, nurse or other medical professional, so symptoms within that timeframe don't need mentioning if they've not required you to see a doctor/nurse etc within that timeframe.

There was no application as it was a benefit I signed up for with work. Symptoms I experienced before was 15 years ago 😢 but they advised that as the clause states I had 'symptoms whether diagnosed or not ' that's why they won't pay out claim.

HSBC declined claim

Ah ok, so it was a claim under a Group Critical Illness Policy.  That definitely makes it more difficult as they do have these pre-existing condition clauses written into them.  That said, it appears a bit contrary to acting in good faith that the symptoms were 15-years prior to the claim and so could potentially usee these clauses if someone has ANY sort of symptom within their life.  If this was me, I'd probably complain to HSBC on this basis and then if that was declined I'd contact the Financial Ombudsman Service and refer it to them.

Good luck.

It does appear that at least in this case the symptoms were plausibly related to the later condition, even if not diagnosed at the time.

Quite possibly/probably, but had this been a personal policy the symptoms would've either been outside the timeframe they needed to be disclosed (typically 5-years for things like numbness, pins & needles etc) OR would've been disclosed and the underwriters would've made a decision on the back of them leaving the client in a clear position of knowing what they were or weren't covered for.  In this instance, symptoms which the client was led to believe were inconsequential have had a massive effect 15 years down the line.

sheramber

Should your employer asked you about any previous medical history before adding you to the policy?

DullGreyGuy

sheramber said:

Should your employer asked you about any previous medical history before adding you to the policy?

Just like the insurance you buy yourself employers have different options when buying group policies for their employees. I've done more work on group PMI than CI but imagine it would be similar. You can buy the cheap policy that excludes everything, the really expensive policy that covers everything, a middle of the road one that may have a "within X years" period or the variable one with individual underwriting for each member of staff included. 

With PMI its not always a one size fits all, some may do individual u/w for Execs and Director Of and do blanket exclusions for everyone below. 


Group policies for the employees is not an advised sale. You need to read and understand the policy yourself to determine if it's suitable for your needs or if you'd be better buying elsewhere.