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  • FIRST POST
    • BooJewels
    • By BooJewels 7th Apr 18, 7:13 PM
    • 229Posts
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    BooJewels
    Critical illness claim; consultant won't send in paperwork
    • #1
    • 7th Apr 18, 7:13 PM
    Critical illness claim; consultant won't send in paperwork 7th Apr 18 at 7:13 PM
    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?
    Last edited by BooJewels; 08-04-2018 at 9:10 AM. Reason: Found a wee typo.
Page 1
    • dunstonh
    • By dunstonh 7th Apr 18, 7:31 PM
    • 92,131 Posts
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    dunstonh
    • #2
    • 7th Apr 18, 7:31 PM
    • #2
    • 7th Apr 18, 7:31 PM
    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.
    I am an Independent Financial Adviser (IFA). Comments are for discussion purposes only. They are not financial advice. If you feel an area discussed may be relevant to you, then please seek advice from an Independent Financial Adviser local to you.
    • Quentin
    • By Quentin 7th Apr 18, 7:46 PM
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    Quentin
    • #3
    • 7th Apr 18, 7:46 PM
    • #3
    • 7th Apr 18, 7:46 PM

    I would be inclined to complain to the NHS trust.
    Originally posted by dunstonh


    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?
    Last edited by Quentin; 07-04-2018 at 7:51 PM.
    • BooJewels
    • By BooJewels 7th Apr 18, 8:00 PM
    • 229 Posts
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    BooJewels
    • #4
    • 7th Apr 18, 8:00 PM
    • #4
    • 7th Apr 18, 8:00 PM
    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
    • By danceinthedark 9th Apr 18, 8:05 PM
    • 5 Posts
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    danceinthedark
    • #5
    • 9th Apr 18, 8:05 PM
    • #5
    • 9th Apr 18, 8:05 PM
    Sorry youíre 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, thatís 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 wonít do it? Are they aware that itís a protection insurance claim and not a claim in negligence against them or another doctor? Iíve dealt with doctors in the past who would only provide a report if they received confirmation that it wasnít for litigation purposes.

    Fingers crossed you get this resolved soon - your insurer will hopefully pursue other avenues if they canít make a decision based on the evidence they have already
    • danceinthedark
    • By danceinthedark 9th Apr 18, 8:10 PM
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    danceinthedark
    • #6
    • 9th Apr 18, 8:10 PM
    • #6
    • 9th Apr 18, 8:10 PM
    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
    • By dunstonh 9th Apr 18, 8:14 PM
    • 92,131 Posts
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    dunstonh
    • #7
    • 9th Apr 18, 8:14 PM
    • #7
    • 9th Apr 18, 8:14 PM
    On what grounds do you suggest making a complaint?
    Cos why not?
    I am an Independent Financial Adviser (IFA). Comments are for discussion purposes only. They are not financial advice. If you feel an area discussed may be relevant to you, then please seek advice from an Independent Financial Adviser local to you.
    • agrinnall
    • By agrinnall 9th Apr 18, 8:16 PM
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    agrinnall
    • #8
    • 9th Apr 18, 8:16 PM
    • #8
    • 9th Apr 18, 8:16 PM
    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
    • By BooJewels 9th Apr 18, 10:05 PM
    • 229 Posts
    • 164 Thanks
    BooJewels
    • #9
    • 9th Apr 18, 10:05 PM
    • #9
    • 9th Apr 18, 10:05 PM
    Sorry youíre having difficulties with your claim. I used to be a CI claims assessor and unfortunately this happens sometimes.
    Originally posted by danceinthedark
    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, thatís 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 wonít do it? Are they aware that itís 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
    • By BooJewels 9th Apr 18, 10:29 PM
    • 229 Posts
    • 164 Thanks
    BooJewels
    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
    Originally posted by agrinnall
    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
    • By ripplyuk 10th Apr 18, 1:18 PM
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    ripplyuk
    Hopefully your insurer has enough info but either way, Iíd make a complaint to the GMC about this consultant. His refusal has caused stress at an already difficult time.

    Itís not an NHS issue so I wouldnít complain there but you can put in a subject access request for copies of absolutely everything if you want (max £50 fee). Iíd make it clear to them that this request is purely because of the said consultantís refusal to fill in a simple form.
    • BooJewels
    • By BooJewels 10th Apr 18, 1:54 PM
    • 229 Posts
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    BooJewels
    Hopefully your insurer has enough info but either way, Iíd make a complaint to the GMC about this consultant. His refusal has caused stress at an already difficult time.
    Originally posted by ripplyuk
    It has indeed. We've just been bereaved too, so could do with a turn in fortunes. I'm going to hold this in reserve for the time being - to revisit later. We still have to have a working relationship with this doctor and I need to let the claim run its course for the moment. As it's my husband's care, ultimately he will decide how to proceed in this respect. But he did say that he wasn't going to let this one rest - if not for his sake, but for those that follow. Sometimes you have to take a stand to improve things for others.

    The insurers were supposed to ring me yesterday to discuss alternative ways of getting the information to them that they need. But as they haven't yet, I'm hoping this is because they've decided that they've got enough already. It's possible, looking at dates, that the GP has already sent the more technical letter I just realised that I have, as they sent a package off a couple of days after we got our copy.
    • danceinthedark
    • By danceinthedark 10th Apr 18, 6:09 PM
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    danceinthedark
    When you speak to the insurer, try to specifically ask the question !!!8216; Have you been able to confirm that the policy definition has been met? !!!8216; because in all honesty, they should know for definite if they have enough from the GP. Having a copy of the initial biopsy results, or a consultant letter to that effect, is often the minimum requirement to confirm the diagnosis meets the policy definition for cancer (although there are some exceptions to this, including !!!8216;new!!!8217; definitions of prostate cancer). Although they may have only approached the GP initially for info about his medical history and not the diagnosis, they should be on the ball enough to identify information that also can be used to confirm the diagnosis, particularly when they know the consultant is not forthcoming.

    Do let us know how you get on - it may be that they have to obtain internal sign-off on a decision if its outside their usual evidential requirements, which could explain the delay in calling you
    • BooJewels
    • By BooJewels 10th Apr 18, 6:46 PM
    • 229 Posts
    • 164 Thanks
    BooJewels
    When you speak to the insurer, try to specifically ask the question 'Have you been able to confirm that the policy definition has been met?'
    Originally posted by danceinthedark
    Thanks for that, I'll note that to ask next time we speak. There is a question in the form to the GP that details the cancer definitions and asks if the GP believes the definition has been met and he's answered 'yes' (i.e some cancers in situ and pre-cancers aren't covered etc.). We also heard a little while ago that the underwriters had passed the condition he's claimed for as one they cover.

    So we can only assume from that point that they wanted confirmation that he definitely had a firm diagnosis of that condition. I think they've had several pieces of material that confirm the diagnosis, from us and from the GP - including copies of the consultant's letters. But when the consultant first voiced reluctance, we rang and asked if we could manage without his report or provide alternative materials and after a while on wait, the underwriters apparently said they couldn't proceed further without it. I think their view has softened on this in the last week after receipt of more materials from the GP after they questioned what they thought was a pre-existing condition mentioned in a 6 year old letter - which was a mistake and the GP has clarified.

    Although they may have only approached the GP initially for info about his medical history and not the diagnosis,
    The initial GP form was quite brief, but did ask some rudimentary medical history questions about how long he'd been a patient and about smoking and alcohol consumption and also asked, as mentioned, if the diagnosis met their cancer criteria and for a brief description of the current diagnosis - he explained and enclosed all of the consultant's 25 previous letters.

    they should be on the ball enough to identify information that also can be used to confirm the diagnosis, particularly when they know the consultant is not forthcoming.
    I think this is where we're at now, realising that the consultant may never provide answers directly, but they do have a lot of information from him indirectly already.

    Do let us know how you get on
    I will do, thanks for the help. I've been searching myself to try and find information on people with similar claims/medical conditions etc. and found little, so it might help someone else reading too.
    • BooJewels
    • By BooJewels 10th Apr 18, 6:57 PM
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    BooJewels
    I meant to add; we also had a secondary claim approved for a credit card with the same company - we found by accident that the PPI on it included critical illness and they've already settled this by paying the entire balance on the card, so they must be reasonably happy that he met the diagnostic criteria. We hoped at the time that it was a good omen.

    Although I would imagine there must be a point where it costs more to investigate than the value of the claim and unfortunately (as it were, for us) it wasn't a card we used much and didn't have much of a balance, so they will presumably have settled that without needing anything like as much confirmation as the significantly bigger lump sum mortgage payout.

    But you'd think that he either meets the policy requirements or he doesn't.
    • BooJewels
    • By BooJewels 12th Apr 18, 11:18 AM
    • 229 Posts
    • 164 Thanks
    BooJewels
    Just to post an update: I finally got the call back, but it seems to have been a spectacular case of crossed wires, causing a waste of time for all parties. This supervisor wasn't ringing to answer what would happen if we didn't get the report from the consultant and how else we might get that data, or if indeed we already had enough to make a decision. She was ringing because it was recorded that I'd lodged a complaint about how long it was taking and demanded to speak to a supervisor. That couldn't possibly be further from the truth.

    In fact the lady I spoke to last week apologised for now long it was taking and I actually said that she had no need to apologise at all as she wasn't the one causing the problem and told her how everyone at the insurers had been kind and patient with us and were about the only party involved that I wasn't unhappy with. I'm actually mortified that my comments have been recorded as a complaint in any way - it truly, truly wasn't. I explained all this and she said it was likely that customer care would follow up on it, so I could explain to them. She had no idea about the answers to the questions I'd actually asked as it wasn't her department. We've now had an additional week of pointless tension.

    The good news is that the consultant has now sent in his report after all and they got it this morning. I think our specialist nurse (funded by Macmillan) applied pressure and helped him complete it and then posted it off. It will go to the underwriters with everything else to make a decision. We're all hopeful now that they have all they need and there won't be any further delays.
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