Critical illness cover - advice greatly needed!!!

[Inactive_User]

I have recently been diagnosed with RRMS and remembered that I have critical illness cover through my employer which I took out on 1st January 2011 - I am therefore 23 months in from my policy start date. At the beginning of the policy I was not required to fill out any medical forms or inform them of my medical history as this was one of the perks of being ‘staff’.

I made a claim which has been rejected on grounds of ‘pre-existing symptoms’.

I questioned their decision and they said that as I had visited my doctor with various symptoms over the last 10 years(headaches/migraine, pain/weakness in left arm - outcome of doctors assessment was that it was caused by a trapped nerve, repeated urinary infections which were never properly diagnosed and I was told just to ‘live with it’ and bowel issues - the tests carried out proved inconclusive). As they could never properly diagnose a reason for my individual symptoms they decided that they must be caused by one problem and this led to my recent MS diagnosis.

The possibility of MS was only mentioned 6 weeks ago so it wasn’t as if it had even been considered a possibility before I took out the policy and it certainly wasn’t mentioned in my medical records prior to this.

The insurer has referred me to the below section of my policy in relation to the rejection of my claim:

(e) No benefit (or increase in benefit) will be payable for any critical illness occurring within two years of the date of a member becoming covered (or the date of increase in benefit), or, if later, the date of the inclusion of that critical illness in the Group insurance scheme, which, in the opinion of Scottish Widows’ Principal Medical Officer has resulted either directly or indirectly from any ‘related condition’ (see below) for which the member:

has received treatment;

has suffered symptoms of;

has asked advice on; or

was aware existed at the time of, or prior to, the relevant date.

Multiple sclerosis	Any form of neuropathy, encephalopathy or myelopathy (disorders of function of the nerves) including, but not restricted to, the following: abnormal sensation (numbness) of the extremities, trunk or face weakness or clumsiness of a limb double vision blurred vision partial blindness ocular palsy vertigo (dizziness) difficulty of bladder control optic neuritis spinal cord lesion abnormal MRI scan

Having read their list of ‘pre-existing symptoms’ it appears to me that if I had sneezed in 2001 I would not be covered for Multiple Sclerosis. I mean there must be millions of people out there who have been to their doctor with headaches, urine infections and trapped nerves. How on earth are you supposed to know that years later you could develop MS and that the symptoms you experienced in the past could have been an early sign?

It seems to me that they have latched on to these ‘symptoms of MS’ just so they can reject my claim. If they were so hung up on previous conditions/symptoms then they should have checked my medical history before they accepted my policy.

As it stands I am now £589.59 out of pocket thanks to the premiums I have already paid with no real cover to claim on.

Does anyone else think they have been underhand about this situation and does anyone know if I have any grounds to challenge their decision?

[ggood]

I think this article below will alleviate your worries.

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. Of course if you live in Scotland it is a precedent.

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; as they are wriggling I suggest you contact the financial Ombudsman.

George