Critical illness claim; consultant won't send in paperwork

BooJewels · 7 April 2018 at 7:13PM

As I've touched on in other threads, we currently have an outstanding critical illness claim in progress, submitted towards the end of January. We are confident that every aspect of it should be in order and there should be no reason not to settle in full. The underwriters already passed my husband's medical condition as being one they cover, so that was the main hurdle that claims tend to fail at, overcome.

There was a modest dispute over what the underwriters felt might be a non-disclosed medical condition, but we believe this has now been addressed. I don't believe that's pertinent to my question here, but I'm happy to explain if anyone wants to know more.

The problem we now face is that the consultant treating my husband, who he has been seeing for over 6 years now, has pretty much refused to fill in the forms / write a report to the insurers and yet this is a requirement of our claim. The GP on the other hand has been a total star, so they already have quite a lot of data from him, from his initial form to answering subsequent questions - see the previous paragraph.

Reading through BMA and GMC docs on line, as well as ABI standards, it would appear that there is guidance as to how they must be fair and honest in such forms and not make moral judgments about whether the patient has any business making the claims involved, but seemingly no requirement to actually do them, as they don't fall under the duties of their NHS contracts. They're allowed to charge a fee (I know the insurers have offered to pay their usual fee and to submit a bill when they return the papers) and I have no problem with that as it is clearly outside their normal duties and they may do it in their own time.

But if the doctor refuses to provide the information, is there any other route to getting the same data to the insurers? Has anyone encountered similar difficulties? I'm wondering if hospital records or admin staff could provide the same information?

I have a call in with the insurers and they're going to ring back after they've done some more digging at their end. They have suggested that the extensive package they already have has now been presented to the underwriters in its entirety and it's possible that they feel that they have enough data to make a decision, but I won't be holding my breath.

We knew it wouldn't be a walk over and expected a bit of back and forth before a decision, but this wasn't a hurdle we factored in - we sort of assumed that the medics would have his best interests at heart and be happy to help. I looked the consultant right in the eye this week and explained gently that without this potential settlement, the next phase of treatment he was suggesting just wouldn't be possible for us to consider and he just shrugged like it wasn't his problem and looked away without saying a word.

Anyone had a similar issue they've overcome by other means?

dunstonh · 7 April 2018 at 7:31PM

Insurance companies pay a lot of money to surgeries and doctors to complete the forms. Its a good money maker for them. I have never heard of any NHS doctor refuse to complete the questionnaire before.

I would be inclined to complain to the NHS trust.

Quentin · 7 April 2018 at 7:46PM

dunstonh wrote: »

I would be inclined to complain to the NHS trust.

Doctors writing insurance reports isn't anything to do with the NHS or employing NHS trust (which is why the insurers pay for them!)

Doctors aren't bound by their NHS contracts to complete these reports

On what grounds do you suggest making a complaint?

BooJewels · 7 April 2018 at 8:00PM

I spoke to my GP about it yesterday during a check up of my own and she felt it was a matter that should be complained about - not so much about the lost fee but the potential consequences to patients of losing their home or being put in serious financial hardship for the want of a bit of paperwork. The GP's comment to my husband was that this was the very least he could do to try and make his difficult circumstances better.

Who does the money go to - the GP implied it goes straight into the practice coffers (they employ a lady who does the admin on all these forms), but the consultant's secretary told my husband that when he does rarely do these forms, he doesn't claim the free as he doesn't need the money - so that doesn't sound like it would go into hospital funds. Maybe he should do them and claim the fee for the hospital if he doesn't need it or has moral objections.

danceinthedark · 9 April 2018 at 8:05PM

Sorry you’re having difficulties with your claim. I used to be a CI claims assessor and unfortunately this happens sometimes. If they are looking for evidence of test results to confirm the diagnosis, that’s usually easy to obtain from another source e.g letters sent from the consultant to your GP, or by requesting the raw medical records directly from the hospitals records dept, bypassing the consultant. The difficulty will be if they are waiting for something that is more subjective, e.g his opinion on future treatment options, current symptoms/deficits and the likelihood of recovery etc. If the cause of the claim is a neuro condition, for example, this type of information may be needed to determine whether the policy definition has been met, as opposed to a claim for cancer where they may only need evidence of biopsy results

Has the consultant said why they won’t do it? Are they aware that it’s a protection insurance claim and not a claim in negligence against them or another doctor? I’ve dealt with doctors in the past who would only provide a report if they received confirmation that it wasn’t for litigation purposes.

Fingers crossed you get this resolved soon - your insurer will hopefully pursue other avenues if they can’t make a decision based on the evidence they have already

danceinthedark · 9 April 2018 at 8:10PM

With regards to fees - generally the invoices from consultants would always be payable to the individual, and for GP reports the fee would be paid to the surgery. I very rarely saw invoices to pay the hospital.

dunstonh · 9 April 2018 at 8:14PM

On what grounds do you suggest making a complaint?

Cos why not?

agrinnall · 9 April 2018 at 8:16PM

If it is the information that's required rather than the form being completed by your consultant then you have a right to see your records, although you might have to make a request under the Data Protection Act.

https://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Pages/what_to_do.aspx

BooJewels · 9 April 2018 at 10:05PM

danceinthedark wrote: »

Sorry you’re having difficulties with your claim. I used to be a CI claims assessor and unfortunately this happens sometimes.

Thank you. At the moment this is causing us more distress than anything else, as it seems to be the one thing that's eminently fixable.

If they are looking for evidence of test results to confirm the diagnosis, that’s usually easy to obtain from another source e.g letters sent from the consultant to your GP, or by requesting the raw medical records directly from the hospitals records dept, bypassing the consultant.

They've already had a copy of all 25 letters the consultant sent to the GP since 2011, some of which we also sent with our application, along with letters from another consultant we saw that led to this recent diagnosis. So we feel that they've already had quite a lot of compelling data, including things like a copy of his chemo consent form. The diagnosis should be beyond dispute and the underwriters have already passed the condition itself.

They didn't ring today a promised, but I'm going to leave them to it for a couple of days, hoping that if they look through it all, as they've said they will, they'll be able to make a decision on the information they already have. I think the only reason they might not is if they have some query that's not already addressed. I remembered this morning that we have one more letter that I think has arrived since everything was sent to them by the GP, from our consultant to another one that will manage the next stage of his treatment. It's a more technical document with test results, biopsy findings, his response to treatment and the next stage they're planning etc, so when I speak to them, I'll offer to send this if they need more still.

The difficulty will be if they are waiting for something that is more subjective,

I can understand how for something like 'permanent disability' , an opinion and prognosis might be more important than pure data, but I don't think that is the case here. His diagnosis and treatment are outlined in several docs they already have.

Has the consultant said why they won’t do it? Are they aware that it’s a protection insurance claim and not a claim in negligence against them or another doctor?

Apparently he just doesn't do then, they're seemingly not important to him. He thinks his time is better spent on patients - he says there aren't enough hours in the day and he can see 3 or 4 patients in the time he would spend on one form. He knows exactly what the nature of the claim is and we asked him before we submitted it. He gave no suggestion at that time that he'd have an issue with it down the line.

Fingers crossed you get this resolved soon

Thank you kindly. I hope so too. He's been offered a great treatment opportunity, but it will necessitate a chunk of time off work and without sick pay, that's just not possible without this settlement. We explained this to the consultant but he seemed totally unmoved by our predicament. I'm struggling to consolidate the idea of him trying to save his life on one hand, but jeopardising his well being and choices and outcomes on the other.

Thanks for your assistance.

BooJewels · 9 April 2018 at 10:29PM

agrinnall wrote: »

If it is the information that's required rather than the form being completed by your consultant then you have a right to see your records, although you might have to make a request under the Data Protection Act.
https://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Pages/what_to_do.aspx

Thanks for the link, I'll keep that available as an option.

As I've just outlined to danceinthedark, I think they should actually have enough data now to make a decision, his condition/diagnosis is pretty conclusive, as is his current treatment and future treatment plans.

I suppose it just depends on how specific their internal procedure is to require particular boxes to be ticked. They do have a recorded trail of calls to his secretary and reminder letters sent (initial request was sent early Feb), so they know he's received it and been reluctant to respond thus far.

The insurance department did tell me at the end of last week that they already felt they had a considerable body of evidence, even without hearing from the consultant, so have already forwarded the entire package back to the underwriters for consideration. It just depends if they come back and say they'll wait for that report before making a final decision.

ripplyuk · 10 April 2018 at 1:18PM

Hopefully your insurer has enough info but either way, I’d make a complaint to the GMC about this consultant. His refusal has caused stress at an already difficult time.

It’s not an NHS issue so I wouldn’t complain there but you can put in a subject access request for copies of absolutely everything if you want (max £50 fee). I’d make it clear to them that this request is purely because of the said consultant’s refusal to fill in a simple form.

Critical illness claim; consultant won't send in paperwork

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