Forum

Critical IIlness appeal

I claimed on my critical illness insurance policy in 2005. It was declined by the insurer due to ‘non-disclosure of material facts’. They did refund the payments that had been made up until the date of the Claim though.

I had applied for the insurance policy through our Bank as cover for Mortgage application in 1995. I knew I should have told the girl who was dealing with our application, that I had been being treated by a Chartered Clinical Psychologist since 1993. But, I was seeing her because of the O.C.D. I had developed as a coping mechanism over the Sexual Abuse I had had as a young girl (Primary School age). I didn’t want to even chance being asked why I’d been seeing a Psychologist, by someone I’d known for a few years in the bank (where I’d had a part-time job a few years before). I was also taking ‘Propranalol’ for anxiety prescribed by my G.P. at the same time, which I didn’t declare.

I know it was a stupid error on my part, not to tell, but all I could think about was : what if the abuse my sister and I had experienced was discovered and it somehow got back to our parents, who didn’t, and still don’t know happened!

I am now thinking of appealling against the decision made by the insurerers, but I’m scared and not quite sure how to go about it.

If anyone has any advice for me if would be welcomed.

If seeing a Chartered Clinical Psychologist had nothing to do with MS it sounds like the Insurance Company are trying to wriggle out of it. Mind you they ask for all medical info to be given.

I would argue that you did not think seeing a Chartered Clinical Psychologist would have any relevance as it is not classed as a ‘Critical Illness’ so would never come to a claim. Just like the Cuthbertson claim (see below) she did not disclose 5 appointments with GP as she did not think they were relevant.

MS patient wins cash battle with insurer
A woman with multiple sclerosis has won a legal battle with an insurance firm that refused to pay out under critical illness policies after she was diagnosed with the illness.

The exact worth of Valerie Cuthbertson’s Court of Session victory over Friends Provident has still to be finalised, but she should receive about a £50,000 lump sum and a weekly payment of £139.

The court heard that the firm had used questionable methods in its search for evidence to invalidate the policies and had latched on to entries in Ms Cuthbertson’s medical records. She had not disclosed a handful of appointments with her doctor in the application forms for the insurance, but the judge ruled that she had no reason to believe those were of any importance.

Ms Cuthbertson said: “It has been a long time, five and a half years, but I felt I had to take it all the way because they were wrong. I felt I had a really good case, and I think for anybody else going through this sort of thing, they will take heart from this.”

Ms Cuthbertson, 39, a theatre manager from Glasgow, took out the cover in 1994. Nearly two years later, she was diagnosed with MS but did not appreciate that the policies covered her condition and made no claim.

Then, in 1999, a representative of Friends Provident called on her to review her financial affairs. He arranged for a claim form to be sent to her and Ms Cuthbertson submitted it.

Friends Provident obtained a report from her consultant neurologist, who confirmed an unequivocal diagnosis of MS. A request was then made to her GP for sight of her medical records.

In his judgment yesterday, Lord Eassie said: "The letter referred to the notes being required to help [the firm’s] chief medical officer in the assessment of the claim and stated that they would be given ‘careful and sympathetic consideration’.

“However … [the firm] had already obtained all the information they required to satisfy themselves that [Ms Cuthbertson] had multiple sclerosis, and the only purpose of recovering the GP records was to see whether … there was any entry which might give grounds for avoiding or invalidating the policy under which the claim was being made.”

Friends Provident did reject the claim on the ground that Ms Cuthbertson had failed to disclose her full medical history.
In its defences, Friends Provident cited five consultations with the GP which, it claimed, ought to have been disclosed. Those took place between 1990 and 1994 and involved complaints about eye pain, an ear problem and tingling in a leg.

Ms Cuthbertson’s neurologist said that, with the benefit of hindsight, and knowing her now to have MS, it might be possible “to discern in some of the entries a possible indication that she was developing the unfortunate disorder”. However, he would not have expected a GP to have been alerted to the possible significance of the incidents.
Lord Eassie said: “I am satisfied that, at the time of answering the matters raised in the application forms, she did not think that the consultations with her GP were of any materiality.”

Source: The Scotsman ©2006 Scotsman.com

Although it is not precedence in the UK because of EU laws a judge will take this into consideration.

This ‘deferral period’ is probably referring to your claim time. I seem to remember a person who’s Insurance Company would not pay him as there is a difference in getting your CI through your work or privately. Through your work have I believe a 2 year period before you can claim; I may be wrong on this.

Also see http://www.thisismoney.co.uk/money/news/article-2287035/Financial-Mail-wins-280k-payout-MS-sufferer-spent-3-years-battling-L-G.html

This means it’s a precedent in England.

George

Thank you George for replying. Would you advise that I appeal to the insurance company or go straight to the Ombudsman?

Try to solve it before legal proceedings with the info you now have. It’s not going to be easy; may take some time; might even see if someone will take it on no win; no fee if it comes to litigation?

G

I would definitely appeal it, a material fact is anything that would affect the underwriters decision of providing cover. For example a previous neurological incident. The fact you were seeing a psychologist is not a symptom or sign of MS and therefore would not have affected their decision in providing you with the cover. I am an underwriter so happy to read the wording and comment for you to base your letter on.

I agree with the previous replies get your appeal in also consider taking your case to the ombudsman. I also claimed on my critical illness cover which was linked to my mortgage , luckily I had no problems and mine paid out but I dont think there were many clauses in my policy it was a new product being offered. Honestly as if you don’t have enough to deal with without them trying to wriggle out of paying and as we all know stress will do you no good at all. I wish you success