Critical illness claim refused - need to vent!!!!

Everyday living
1

18 months ago I took out my first mortgage and thought it would be a good idea to take out some insurance policies to ensure we would be ok financially should the worst happen. I decided to take out a separate critical illness policy which would pay out a lump sum, enough to cover the mortgage. There was no medical questionaire to fill in at the time of application and I was immediately accepted for full cover.

In October 2012 I visited my doctor due to various unusual symptoms I had been experiencing for a few weeks and was immediately referred to a neurologist.

I was subsequently diagnosed with MS in January 2013.

I checked the critical illness cover we had taken out and MS was one of the covered illnesses - the policy did state that no amount would be paid out in the first 2 years from the policy start date had I ever suffered from, sought advice on or been given treatment for any of the ‘pre-existing related symptoms’ of MS.

MS had never been mentioned to me prior to October 2012 and I therefore was of the opinion that I must never have suffered from any of the ‘pre-existing related symptoms’ of MS or surely my doctor would have mentioned this.

I submitted my claim on 28th January 2013 and have received a letter from the insurance company today advising me that my claim had been rejected and I would no longer be covered for MS should I wish to continue with the policy!!!

I rang them only to be told that they were declining my claim due to me suffering from blurred vision in my left eye and tingling/weakness in my left arm, which was documented in my medical notes in 2006. I obtained a copy of my medical notes in January 2013 for my reference so I decided to look up the entry they had used to decline my claim.

My GP had written the following:

‘patient advised migraines are becoming more frequent and difficult to manage on current pain-killers. Migraines present as left sided head, neck and shoulder pain with aura in left eye and tingling/slight weakness down left arm (probably caused by muscle tension in shoulder/neck). Patient history confirms she has suffered from migraines for several years. Reflex tests are normal. Prescribed co-codamol.’

They have therefore said that abnormal sensation, blurred vision and weakness are ‘pre-existing related symptoms’ of MS and therefore my policy was null and void for MS.

I have spoken with my cousin today who is a GP and he has confirmed that migraine can cause all of these symptoms but it does not necessarily mean that the migraines and MS are linked. They can be two completely separate conditions causing similar symptoms. He also said that had my GP had even the slightest suspicion that I may have had MS he would have referred me to a Neuro back then. It is also clear from my medical notes that I have suffered from migraines for years it’s just unfortunate that on this one occasion my doctor has fully decribed the symptoms of my migraine in my notes. The actual symptoms were never mentioned in any previous notes and they simply said ‘migraine’.

Do you think it would help my case if I could persuade my Neuro to write to the insurance company confirming that it would be impossible to confirm whether the migraine and MS were linked?

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Hi Anon,I’m guessing that refusing a first claim is pretty standard for insurance companies.May I humbly suggest that you carry out the actions you talk about and find out about the insurance industry complaints proceedure,keep copies of all correspondence and be prepared to get cosy with the Ombudsman if need be.

Good luck,

Wb

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you realy do need to take this up with the Ombudsman. you will get a yes or no and their decision is final

4

I think your issue is not so much that they can’t prove it was linked to MS, but that you can’t prove it wasn’t.

I believe the burden would be on you to show it wasn’t an early warning sign - which they’re obviously claiming it was. I don’t know if you will find anyone to say it definitely couldn’t have been the start of it, because it’s one of those things you can probably never tell.

I had a single isolated migraine, having never had one before, a few years before diagnosis. I realised at once what it was, as other family members are sufferers, so luckily for me, I never bothered seeing the doctor. If I had, I’d probably have run into the same problem as you - i.e. reports of a neurological change that might have been interpreted as a “warning sign”.

I’ve still no idea whether that migraine was an early sign something was wrong, or had nothing at all to do with it. I’ve never had another, but it’s odd to get one at all, when you’ve no past history.

Tina

5

Write one letter back saying your appealing the decision and going to the ombudsman…put in this that migraines can cause the described symptoms etc and see what you get back…if no joy go to the ombudsman. They rejected us first, so my mum (believe me you don’t wanna get on the wrong side of her) wrote a letter threatening to go to the ombudsman and going through things in detail etc…within a month we had a cheque through the post for the remainder of our mortgage! Put a good letter together that shows you mean business, if your not great at composing a letter use citizens advice. Don’t give up, it’s your right…they will try and get out of it as that’s insurance for ya. Xxx P.s keep us posted too x

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I totally agree with Lisalou (and her mum). Write a letter to the claims dept. let them know you’re giving them the opportunity to review their decision before you approach the ombudsman. Give them a date to respond by.

If possible, get together as much written extra support for your claim as possible from professionals: gp, neuro etc.

Good luck x

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my sister in law put in a claim on her mortgage cover when she was diagnosed with ms. the insurance company then tried to imply that things she had visited the doctor for in previous years could have been symptoms of ms and therefore said they wouldn’t pay out. however, she contested this using the grounds that ms had never been mentioned to her nor previously recorded as a suspicion held by the doctor. she then had her mortgage paid off. DO challenge this and threaten to kick up a real stink about it - it is your right! it makes me so cross that they try to wriggle out of their contractual obligations. your neurologist/consultant should back you up on this.

wishing you the best of luck to get this resolved without much more stress x

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Hi,

You are right to be apprehensive about your CI but as you can see from the article below you should be alright. This is exactly the same circumstances as your claim.

Insurance companies have a department named ‘How to wriggle out of claims’ and this is for future reference just in case. They may say something like ‘you had a cold in 1988, reported to the GP, this was obviously the start of your MS and you should have known.’

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 a 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.

Good luck, as you have done claim; suck it and see.

George

9

Hi there,

Please don’t give up on this! I had a my CI claim refused by Scottich Widows for ‘ticking the wrong box’ about blurreed vision. I had to argue my case and initially this was upsetting, stressful and not at al productive. It was only after I decided to seek legal help from Mr.Google, [edited], that I felt someone actuallu understood my plight. Two brilliant solicitors, who had both suffered personal tragedies and misjustice at the hands of the insurance companies themselves, handled my case. [edited]. After a two year ‘batlle’ (and that is what it was) I won my case, had the judgement overturned by the Ombudsman (after they sided with SW initialy at appeal) and also received compensation and interest. I was one of the lucky ones and could not have done it without the support [edited]. I actually felt that afrienship had come to an end when it was all over! Of course, there was a fee which was fractional of my overall payment but worth every penny.

These companies are great at finding loop holes and making pepole feel like liars at a time when support is needed most. You ought a product in good faith. Blurred vision is not always a symptom of MS and you don’t have a crystal ball.

Good luck with the fight, but do fight if you can.

Regards

Anon

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Hi can you get a copy of today’s ( Sunday Mail ) 3 rd March? In the money section they have been fighting an exact same case and just won it , Hope this helps , Take Care M

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Thanks for all the replies, good will and help.

charlie b - I have just managed to look up that article online and it does sound exactly the same as my situation. The blurred vision, weakness and tingling were linked to my migraine by my GP and were not considered extreme emought to warrant further investigation at that time. MS was never mentioned to me prior to October 2012 so how was I supposed to know I had it.

I may print off this article and send it to them along with my letter confirming my intention to approach the financial ombudsman.

thanks

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I came across the story myself quite separately and shared it with with my colleagues this morning- it’s such a joy to find a case where the insurance company is made to pay. For those who haven’t seen it and want a little lift…

Stewart (admin)

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Hi I am really sorry to hear about your situation and hope you get the result you are looking for due to great feedback and support from other members. I would say contact FOS financial ombudsman service straight away 0800 023 4567 they have helped a client I know , they are on your side less stress than dealing with the insurance company directly , and the insurance company is more likely to try and put things right in full. Make sure you include as much additional information as possible and explain that the potential of MS had never been mentioned to you so it is more down to the doctor. Present your case in full , in defense of insurance companies most of them have a above 90% success on their claims record. Good luck