Critical Illness Cover

[sparehead03]

Hi Everyone,

My very first topic...here goes.......

A few years ago a person I know developed arthritis in one knee. After many months off work through sikness as a result he/she (to maintain forum anonimity) was dismissed on the grounds that the arthritis made it impossible to continue in his/hers present role.
All releveant claims were made includeing one under the Permanent Disability section of the critical illness policy. The claim was rejected. After months of letters he/she finally gave up to consider the next move.
During this time he/she developed arthritis in the other knee (he/she now walks with the aid of a stick) and then developed Fibromylagia. Another claim was made and this too was rejected on the grounds that he/she could still do the occupation they had registered albeit from a wheelchair if necessary. He/She's occupation did involve some physical labour and mobile duties but generally it was administrative, say 70:30 ratio.
He she was dismissed by the employer for not being able to do the 30% physical part which the insurance company said was unimportant as far as the occupation was concerned because he/she was still able to do the other 70% administrative part in some form for another employer even if it meant doing a different job altogether as long as the admin work could still be done.
This was not he/she thought when the policy was set up as OWN OCCUPATION and not ANY OCCUPATION which seems to be how it is being treated. The insurer appears to have seized on the administrative side of the occupation and said this can make up 100% of any new occupation. That would be okay if the policy said ANY OCCUPATION. Had he/she known this at the time they may have opted for the any occupation policy and saved themselves a considerable amount in additional premium charges. Perhaps there is a case against the financial advisor who sold the policy as well as the insurer.

Anyway the questions that arise are:-

1) With the limited brief above who do you think is right?
2) How might the FOS decide? He/she does not qualify for any legal aid or other assistance.
3) Can a complaint be made against the Financial Advisor for selling an inappropriate policy.

Thanks in advance.

[shas]

Re: Critical Illness Cover

Hiya,

Im not sure where you stand with your critical illness cover. All I know is that I made a claim on mine... because I was tested as having a terminal illness (it says thats a good reason on the paperwork!)... & it eventually went to the ombudsman &......... got rejected!

It was rejected because I wasn't in enough of a vegetative state to be paid out! They didn't argue that I'd tested positive, just that I wasn't incapable enough (physically) at that time & that once I was... I could put my claim in again!

I dont think it matters what your job was... Its whether you are capable of doing anything at all.... unfortunately.

Im sure somebody will point you in the right direction though & good luck with it.

[scoobydoo]

Re: Critical Illness Cover

The other angle ito consider was the employer wrong to dismiss her if she could do most of her job?

[jax007]

Re: Critical Illness Cover

Hi Sparehead

Are you sure this was CRITICAL Illness insurance??

Sounds to me more like Income Protection to me but I could be wrong. Some of these policies pay out for a year if you are unable to work and others will pay out longterm provided you are unable to do ANY kind of work. Again it depends on what type of policy was taken out.

Critical illness policies cover such conditions as heart attack, cancer, stroke, etc ...... ie life threatening conditions. Depending on when the policy was taken out, insurers used to pay on diagnosis but now ... as in Shas's post above ... you have to be at a specific (and critical) stage in the illness before they will pay out.

Arthritis, as debilitating as it is, is not life threatening which is why I question the type of cover your friend has.

[Mochamoo]

Re: Critical Illness Cover

Just a thought...can you get a doctors note to say that BOB (so much easier than she/he lol ) is no longer physically capable of doing the job.

My FIL had mortgage / life insurance he was diagnosed with a terminal cancer 3 years ago and the mortage / life insurance refused to pay out cause he wasn't close enough to death yet the initial doctors note said he had an indeterminate time left, anywhere form 3 moths to a year they thought.

The only way FIL was going to have any decent quality left to his life without going bankrupt and losing everything was for the mortgage/life insuance to pay out... so we had a chat with the doc and explained the situation and they wrote to the insurance company saying he had 3 months left...morbid I know but it worked and 3 years on whilst he is still..just.. with us he hasnt spend the last few years of his life facing bankrupcy and worrying about money.


So maybe getting the doctors to say BOB is not capable of the work anymore will get a pay out.

[jax007]

Re: Critical Illness Cover

The point is Moch that the policy referred to is a Critical Illness Policy (which I have doubts that's what it is). Your FIL had a Life Assurance Policy with Critical (or Terminal) Illness built in. This means that if you are diagnosed with a condition whereby you are unlikely to survive the next 12 months, the policy will pay out. As you rightly point out - you got a doctor's letter to say this was the case. I have just done the same with my husband's Life Assurance Policy. He ALSO had CRITICAL Illness as a separate policy and that paid out on diagnosis which is in the terms and conditions.

I am not convinced that what 'BOB' actually has is Critical Illness cover. Also, doctor's letter or no, arthritis is not life threatening.

[shas]

Re: Critical Illness Cover

I'm not sure if this helps, but the dwp decided that I would never work again & the critical illness cover still didn't kick in.... You literally have to be in a permanent vegetative state or did do with the company I was with (at that time) anyway & if I am being honest, I can't actually afford to work now with what dwp pay me. My cover also said that it would pay out on diagnosis.

It made the mail on Sundays financial mail (yes there was a whole page on me & a picture of me lol) .... the reporter was making people aware of how policies sometimes dont pay out... My financial adviser wasn't impressed either which is why the ombudsman had the final say.

If your friend is unable to work, they may be entitled to everything which I receive, so it may be worth them enquiring.

[sparehead03]

Re: Critical Illness Cover

Believe me, it IS a Critical Illness Policy.
One of the conditions of payout is Total & Permanent Disability through sickness or accident. BOB did claim on a separate policy for income protection but that expired after a year of payout.

Shas thanks for the advice. The DWP and DLA is already sorted.
------------------------------- merged -------------------------------
Also BOB has already sent in reports from two GP's & two independant Rheumatologists to support the case but still nothing.
The next step is FOS and then legal action but that will be expensive. Can't claim for legal cover through home insurance (long story) so need to get after the event insurance cover for legal expenses.

[sparehead03]

Re: Critical Illness Cover

Shas,

As an afterthought have you ever considered appealing the FOS's decision in Court?

BOBs' solicitor wants to take this to Court in the likely event (yes likley; I'm being pessimistic) that the FOS finds in favour of the insurance company. I think the Court is where this will end up.
You never know it might be one of those landmark cases that either closes or opens the floodgates for all those people that have been shafted by the insurance companies. In fact I feel so strongly about this I have even considered setting up some sort of forum specifically for people who have CI insurance to see what the statistics are.