Financial Ombudsman and LV

liveletlive

@DullGreyGuy

Again I appreciate your interest and thoughts, as far as I know you are helping me think this through with nothing to gain, I see that and appreciate it.

• I really must stress I didn't have any symptoms. You must trust me.

If ADHD is or isn't a mental health condition is irrelevant, based on whatever reason they offered you cover excluding mental health cover and you decided to accept that. When I bought my private medical insurance I was offered it with or without mental health cover with a difference of £75 in premiums. 

• I struggle to understand this, if the terms don't exclude ADHD then the insurer is not allowed to claim its not covered. FYI there is no definition of the term mental disorder in the policy documents and the policy does state other mental disorders specifically but does not include ADHD.
• Are you saying they can exclude it because they get to define what they meant by Mental Disorder? (but thats is contradictory to contract law)
• I am still paying nearly £100 for my cover, when I took the policy out I was told they have a two standard period they had a MH restriction. As a I said I asked for the assessment in March and my two years were up in April (foolish I know).
• I have not had any legal advice yet, but the stage its at definitely validates that its not as clear cut ad you understand it to be.

I'm going to stretch your analogy (apologies in advance), to bring it closer to my situation. Lets say your policy covers everything but has the following exclusion.

"We will not cover you index finger, pinky and other fingers".

You lose a thumb

• My question is are you covered?
• Do you class a thumb as finger (some do some don't)
• Why have you said fingers and then specifically mentioned the Index and pinky but not the others?
• >>The insurer and the ombudsman is saying it includes the thumb "as we say we have ten fingers!"
• >>Two independent NHS hand/english experts are saying saying thumbs are medically and in the english language non-fingers?
• >>The insurer and the ombudsman is saying we are going to ignore the independent experts and go with out own opinions.

My argument thumbs are not finger and they are covered, The wording is ambiguous at best the law states ambiguity is to be settled against the person who drafted the contract in this case LV. 

Unrelated:

Given the top rate of income tax is 45% (48% Scotland) thats probably something else you want to look into

Please google 60% tax trap, I'm not allowed to post links yet.

I value your thoughts and engagements but I feel you and others are letting the insurer off the hook to easy, there are rules to protect the consumer. As a landlord I am always held to a high level of scrutiny because I am the professional if I don't give the consumer a document telling them how to rent I have to pay them three months rent! Its the same for insurers and anyone who sell these product.

If you take my story about the accidental damage insurance in my last post that is not transparent. This is industry needs better regulation and the consumers need to push harder to hold the insurers and agents to a higher standard.

Thank you for your thoughts.

 

BarelySentientAI

There are rules to protect the consumer, but there is also an understanding that when a contract is entered in to, then the terms of the contract are what matter and not "what I thought and hoped the contract said".  Similarly, it isn't just "believe the little guy under all circumstances".

One point that I'm not clear about in your argument - was the claim you tried to make based on ADHD?  You only say "a MH claim" in your original post.  That makes a big difference to the understanding here.

If your MH claim was ADHD, then I can follow your argument, although I disagree with it.  You're not on solid ground making an argument that "I didn't have symptoms, honest, but I did an online evaluation just for fun and then decided to ask for a proper evaluation" - and it's almost impossible for you to evidence otherwise.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5 that they seem to refer to) is the standard text for categorising mental disorders in the USA (and generally accepted worldwide).  As ADHD is included in the list of mental disorders - albeit in a subcategory of neurodevelopmental disorder - then it's not the insurer deciding that it is a mental disorder, it's an internationally accepted standard text stating that this is so.

If your MH claim was something else, then your arguments about dictionary definitions and contract law don't follow at all.  It should simply be "did the symptoms of the MH issue start within an agreed exclusion period", and based on your dates they didn't.  Given that you're not arguing that, I'm assuming it's nothing so simple, otherwise you've wasted a lot of effort arguing irrelevant things and confused everyone.

Lots of people think their insurance covers something when it actually doesn't.  Matching set cover, courtesy cars, what an NCD actually is....  That's not the fault of the insurer, and doesn't need "fixing to protect the consumer".

liveletlive

@BarelySentientAI thank you for looking into this post and providing your input. 

I made a claim for PTSD treatment secondary to my daughter's leukaemia. This claim was submitted six months after the exclusion period was supposed to expire, as LV automatically reviews exclusions. However, they only reviewed the exclusion after I made the claim. The ADHD assessment is unrelated; I had a non-medical reason for requesting this assessment. As previously mentioned, I cannot disclose the reason without revealing my identity.

My argument thumbs are not finger and they are covered, The wording is ambiguous at best the law states ambiguity is to be settled against the person who drafted the contract in this case LV. 

Key Points:

1. Ambiguity in Classification: Please refer to the five fingers analogy in the thread, which explains the ambiguity in classifying conditions.

Lets say your policy covers everything but has the following exclusion.

"We will not cover you index finger, pinky and other fingers".

You lose a thumb

• My question is are you covered?
• Do you class a thumb as finger (some do some don't)
• Why have you said fingers and then specifically mentioned the Index and pinky but not the others?
• >>The insurer and the ombudsman is saying it includes the thumb "as we say we have ten fingers!"
• >>Two independent NHS hand/english  experts are saying saying thumbs are medically and in the english language non-fingers?
• >>The insurer and the ombudsman is saying we are going to ignore the independent experts and go with out own opinions.

1. Expert Opinions:

   • I have a letter from an NHS ADHD specialist stating that ADHD cannot be simply classified under the heading of mental health.
   • I also have a letter from an NHS psychiatrist confirming this, providing a medical interpretation of the DSM-5 and ICD-11. Both the insurer and the FOS have disregarded this specialist knowledge and interpreted ADHD as you have.

2. Mind Mental Health Charity:

   • You can contact their legal helpline now, and they will confirm that they do not consider ADHD a mental health condition.
   • LV refers its customers to Mind and claims to work with them.

3. Case Law:

   • Insurance terms should be interpreted narrowly, meaning broad, all-encompassing statements are not valid.
   • Ambiguity in insurance terms should be resolved in favour of the insured.

4. Ethical Considerations:

   • I would not have made the PTSD claim if my daughter had not been ill, impacting me. This situation has no relevance to my request for an ADHD assessment.

Every argument I have presented is backed by reputable evidence and interpretations from credible sources, including written letters and web pages. These are not my interpretations but are grounded in specialist knowledge and authoritative references. 

I am confident that my arguments are logical and not a wasting my time and others because I'm critically evaluating my thoughts and finding primary evidence to support my view. For example unlike the LV administrators and FOS  I am not interpreting medical resources like DSM and ICD myself I have professionals interpreting.

Another argument is that that I don't need to prove that I am right and LV/FOS are wrong, I only need to prove that there ambiguity in classification of ADHD as the contra preferantem rule dictates the ambiguity should be settled in favour of the party that did not draft the contract.

Is the fact that LV/FOS are disagreeing with Mind, NHS Psychiatrist and ADHD doctor not enough to prove there is ambiguity? (I am trying to strip put my own emotions and opinions as much as possible)

Part of the reason why I have asked the question here is to help me identify gaps in my argument. I appreciate your insight.

BarelySentientAI

liveletlive said:

@BarelySentientAI thank you for looking into this post and providing your input. 

I made a claim for PTSD treatment secondary to my daughter's leukaemia. This claim was submitted six months after the exclusion period was supposed to expire, as LV automatically reviews exclusions. However, they only reviewed the exclusion after I made the claim. The ADHD assessment is unrelated; I had a non-medical reason for requesting this assessment. As previously mentioned, I cannot disclose the reason without revealing my identity.

My argument thumbs are not finger and they are covered, The wording is ambiguous at best the law states ambiguity is to be settled against the person who drafted the contract in this case LV. 

Key Points:

1. Ambiguity in Classification: Please refer to the five fingers analogy in the thread, which explains the ambiguity in classifying conditions.

Lets say your policy covers everything but has the following exclusion.

"We will not cover you index finger, pinky and other fingers".

You lose a thumb

• My question is are you covered?
• Do you class a thumb as finger (some do some don't)
• Why have you said fingers and then specifically mentioned the Index and pinky but not the others?
• >>The insurer and the ombudsman is saying it includes the thumb "as we say we have ten fingers!"
• >>Two independent NHS hand/english  experts are saying saying thumbs are medically and in the english language non-fingers?
• >>The insurer and the ombudsman is saying we are going to ignore the independent experts and go with out own opinions.

1. Expert Opinions:

   • I have a letter from an NHS ADHD specialist stating that ADHD cannot be simply classified under the heading of mental health.
   • I also have a letter from an NHS psychiatrist confirming this, providing a medical interpretation of the DSM-5 and ICD-11. Both the insurer and the FOS have disregarded this specialist knowledge and interpreted ADHD as you have.

2. Mind Mental Health Charity:

   • You can contact their legal helpline now, and they will confirm that they do not consider ADHD a mental health condition.
   • LV refers its customers to Mind and claims to work with them.

3. Case Law:

   • Insurance terms should be interpreted narrowly, meaning broad, all-encompassing statements are not valid.
   • Ambiguity in insurance terms should be resolved in favour of the insured.

4. Ethical Considerations:

   • I would not have made the PTSD claim if my daughter had not been ill, impacting me. This situation has no relevance to my request for an ADHD assessment.

Every argument I have presented is backed by reputable evidence and interpretations from credible sources, including written letters and web pages. These are not my interpretations but are grounded in specialist knowledge and authoritative references. 

I am confident that my arguments are logical and not a wasting my time and others because I'm critically evaluating my thoughts and finding primary evidence to support my view. For example unlike the LV administrators and FOS  I am not interpreting medical resources like DSM and ICD myself I have professionals interpreting.

Another argument is that that I don't need to prove that I am right and LV/FOS are wrong, I only need to prove that there ambiguity in classification of ADHD as the contra preferantem rule dictates the ambiguity should be settled in favour of the party that did not draft the contract.

Is the fact that LV/FOS are disagreeing with Mind, NHS Psychiatrist and ADHD doctor not enough to prove there is ambiguity? (I am trying to strip put my own emotions and opinions as much as possible)

Part of the reason why I have asked the question here is to help me identify gaps in my argument. I appreciate your insight.

I think you are arguing entirely the wrong point, which is why you are getting nowhere.

You made a mental health claim for something that is a recognised mental health condition (PTSD) while there was a mental health exclusion still on the policy (until the exclusion is reviewed and removed, it is still there, regardless of when they would typically remove it).

Given that, any discussion of whether ADHD is a mental health condition or not is essentially irrelevant and none of your case law precedent, reputable evidence, or authoritative references means anything at all.  There is no ambiguity.  Your analogy of fingers and thumbs is not an accurate representation of what this case actually is.

Very simply:

Your policy says "we do not cover mental health conditions". - you have clearly stated this exclusion existed.

You claimed for PTSD. - there is no dispute about this.

PTSD is a mental health condition. - there is no dispute about this.

Your policy, therefore, does not cover the claim.

Your only argument can be that the exclusion wasn't automatically reviewed and possibly removed.  Note that they can choose not to remove it for any reason, any reason at all, so logic about the definition of ADHD doesn't help you here either.

liveletlive

@BarelySentientAI

I'm not sure if I agree but its food for thought. I won't dismiss your view as there maybe something I just don't see.

FYI - The reason given for declining the claim is that I asked for an ADHD assessment which contravened the mental health exclusion. I almost lost hope, LV as part of their duty of care referred me to Mind the MH charity, Mind legal team  immediately said "you haven't broke the contract as ADHD is not a Mental Disorder". I then dug asked an NHS Psychologist he agreed, Then I asked an NHS ADHD assessor he agreed.

Ive also asked other professionals at leading universities and organisations and they agreed but couldn't put it in writing as they don't have professional indemnity cover, Note the doctors have put this in writing and so has Mind.

IMO The argument is did not contravene the exclusion clause as ADHD is not a mental disorder.

I'm sorry I am repeating myself now...

I think none of this matters, Ultimately is it a genuine claim yes! I have more chance of winning the lottery twice than my daughter getting this type of Leukaemia this is exactly what insurance is for. Any parent who has seen what I have seen would need support.

BTW - My daughter is beating all the odds, we are at a point of the journey we thought we may not reach.

sheramber

But what about 

 Numerous medical organisations, including the World Health Organisation (WHO) and the American Psychiatric Association (in DSM-5) list neurodevelopmental disorders (such as ADHD) as a type or subset of mental disorders. 

BarelySentientAI

liveletlive said:

IMO The argument is did not contravene the exclusion clause as ADHD is not a mental disorder.
.

But that isn't what you are claiming for, so whether or not it contravenes the exclusion clause is not relevant.  Its impact on the clause, however, is.

I'm not surprised you can find people willing to state ADHD is not a mental disorder.  I could find thousands of professionals who would state it is.

liveletlive said:

FYI - The reason given for declining the claim is that I asked for an ADHD assessment which contravened the mental health exclusion. 

I think it's more likely they are saying "we would not have removed the mental health exclusion because of the ADHD assessment, so it is still in force for the PTSD claim which we have then declined".  And even the sources that don't categorise ADHD as a mental disorder clearly state that people with ADHD have a greater chance of future mental health disorders - so it seems like a defensible decision to maintain the exclusion.

Also, having now read the public record, there are a few other bits in the case that you've forgotten to mention:

Your policy said that you should request the removal of the exclusion, not that it would automatically vanish after two years.  It should still have been in place at the time of your claim because you never asked.  Actually, they treated you extremely fairly by assuming that you would want it reviewed and doing it anyway.

You didn't just "type things in an online tool for fun".  You visited your GP and formally requested an ADHD assessment.

Oh, and the record states that the reason for declining is exactly as I suspected.  The ADHD discussion made LV not remove the exclusion, and PTSD was quite correctly covered by the exclusion.  They did not decline the claim "because you asked for an ADHD assessment".

Your actual complaint boils down to "asking my GP for a formal ADHD assessment is not evidence of any symptoms or treatment that should have made LV maintain the mental health exclusion, and so when they review it (despite me forgetting to ask for the review) it should have been removed".  Writing it that clearly brings a very different point of view to the fore.  But, if you want to complain, that's the bit you need to focus on because it's the only thing that matters.