Critical illness claim rejected

Floflo68

Hi , im a newbie on the forum and hoping to get an idea on peoples views regarding my claim being rejected. 
At the end of last year i was diagnosed with Marginal Zone Lymphoma and told that its in my bone marrow but as yet they are happy to leave me on active monitoring .
As you can imagine the diagnosis was terrifying not only for me but for my friends and family and seeing them cry and be so upset was as painful as me being told i have blood cancer.
We have Critical Illness cover so i decided to put a claim in as i could see lymphoma is a cancer they do generally pay out on . 
To make the claim we had to have reports from our GP and specialist and wait several weeks for the insurance company to get back to us . I could not believe what i was reading when they sent the decision back and said  that my condition is basically a condition that may or may not develop into a Lymphoma ! 
To say i am angry at that comment is an understatement , how can they dismiss someones horrible diagnosis as if its nothing ? I then started to wonder if maybe my specialist was wrong and i didnt quite have Cancer and of course hoped that could be the case so i contacted her immediately only to be told i absolutely have Lymphoma and yes its in the bone marrow and yes its Marginal Zone. Apparently the insurers are saying my level needs to be a 5 to fit the criteria and im only a 4 but i cannot see anything that states those figures anywhere ?. 
I realise i have to give them 8 weeks before i can go to the Ombudsman and wondered if anyone has had a similar experience because i think that the one damaging line making out you do not have a cancer is diabolical and damaging to people who are going through such a traumatic time . 
They should be hauled across the coals for this , its a disgrace !

Flugelhorn

I think you need more info from the insurers about what criteria they are using - the staging of these is usually 1-4 though stage 2 can be split. 

it maybe that their data shows MZL to have a good prognosis and may not meet their criteria for payment - you definitely need to find out under what circumstances they would pay 

DullGreyGuy

Floflo68 said:

 Apparently the insurers are saying my level needs to be a 5 to fit the criteria and im only a 4 but i cannot see anything that states those figures anywhere ?. 
I realise i have to give them 8 weeks before i can go to the Ombudsman and wondered if anyone has had a similar experience because i think that the one damaging line making out you do not have a cancer is diabolical and damaging to people who are going through such a traumatic time . 

Do you have a link to the exact policy wording you have? Wordings change fairly frequently but only for new business, it's one of the significant issues with CI and one of the reasons I dont like it as a product. 

Ultimate CI pays out for certain conditions at certain levels of severity. You can have a really nasty illness but it not payout because it's not on the list or because you are just short of the mark. Two uncles had bypass ops, both had CI, only 1 paid out because both paid out on open chest surgery but by the time the second needed the procedure it was now done by keyhole surgery so he didnt meet the grade. 

You dont need to wait 8 weeks to go to the Ombudsman, you can go as soon as their final response arrives, its only if the final response doesn't arrive that you can go at the 8 week mark despite not yet having their response.

You can search on the Ombudsman website for similar cases, unfortunately the uphold rate is low but there are plenty of others that try to argue they meet the definition but the ombudsman doesn't agree though most of the complaints are a matter of timing (did the policy or condition exist first):

https://www.financial-ombudsman.org.uk/decision/DRN1417447.pdf

https://www.financial-ombudsman.org.uk/decision/DRN-5042013.pdf

The second is one of the few where the ombudsman upheld the case and it covers both the short comings from her insurer but also the additional evidence she was able to provide to support her case.

These kinds of posts are hard to sign off on. Clearly if you're currently a "4" and you need to be a "5" to have a valid claim then you can resubmit the claim in the future if your condition deteriorates. Good luck and hopefully it goes the way you want. 

TELLIT01

I can understand the OP being very upset at the insurer's decision, but looking at information about the condition the median survival period is 8 to 10 years.  On that basis it's less surprising that the claim has been rejected.  The OP can appeal the decision, but also needs to try to live as normally as possible once they have recovered from the initial shock of the diagnosis.  It would seem that they will need to claim later if/when the condition becomes more severe.

LightFlare

It would be surprising if critical illness cover paid out for a condition that the only current treatment being received is active monitoring

It’s really no different than having a suspicious mole being actively monitored - it could develop or it could not.

From a diagnosis perspective- I would suggest looking around for a local support group 

Weighty1

LightFlare said:It would be surprising if critical illness cover paid out for a condition that the only current treatment being received is active monitoring.

It’s really no different than having a suspicious mole being actively monitored - it could develop or it could not.

From a diagnosis perspective- I would suggest looking around for a local support group 

This is my view based on my experience as well.  Yes, a lot of modern policies are designed to cover more early stage cancers as an 'additional condition' but even then it would be pretty unusual for any cancer diagnosis claim to be upheld when the suggested treatment is 'watch and wait'.

OP, this is really no different than something like prostate cancer, which needs a Gleeson score to be more than 6, typically, to be valid for a claim.  Yes, someone with a Gleeson score of 4 still has prostate cancer but it's not going to result in a payout in the majority of cases.

Think of it like this, critical illness cover is designed to provide protection in the event of diagnoses of an awful medical condition that is often going to have life changing consequences, such as impaired mobility, cognitive ability to immune system.  Yes, get ANY cancer diagnosis is awful in terms of the worry it causes but thankfully the condition is highly unlikely to cause you any problems for many, many years.  If and when it does progress then the critical illness cover would be there to claim upon.  Hopefully, it'll never get to that point though.