Hello everyone I just need a little bit of advice if anyone can help I ave 2 separate critical illness insurances now 1 has paid out but the has been declined. Has anyone had a simle problem, if so did you appeal, did you win. Thanks Helen
Can you state the reason you were declined the second critical illness policy from paying out?
If the illness such as ms was not one listed as one which can be claimed against, them maybe their criteria hasnt been met.
Mine specifically stated multiple sclerosis, but I took it out in case of heart problems as my father had such. It was a shock when I was diagnosed with ms out of the blue in the year 2000.
Are you saying the second insurer wouldn’t pay out because the first already had?
Or did they just have different qualifying criteria?
This is going back a long way for me, but I seem to remember from my college days something about if you’d insured against the same event twice, you couldn’t collect the full payout from both. Even if both paid out, they would each only pay a proportion, in recognition that the other was also paying.
The gist of it is to prevent someone being “over-compensated”.
Say for some reason you’d taken out ten critical illness policies (must have had a pretty bad premonition, but nothing to stop you). Are you going to collect ten times the going rate if you get MS?
No, I don’t think so. I think, at best, you’ll get 10% from each of them (or slightly different proportions, depending whether some had higher premiums than others).
I’m guessing this is the essence of the problem in your case. Insurer 2 doesn’t consider they’re liable, because Insurer 1’s already stumped up.
I think, unfortunately, this might be true.
You might need legal advice.
Hi Tina /Bren They are not saying that I don’t meet the criteria, and it has nothing to do with the amount of policy’s that I have unfortunately they are trying to say that I had ms before I took out the insurance which is silly, my doctor has even supported this with a letter. I am just unsure how the appeal process works as this has never really dealt with anything like this before… Thanks for you help, I thing legal advice might be my next step. Helen
I think you will be much better to try the Ombudsman first, after which I think you may still have recourse to legal action anyway. When going to the Ombudsman I think you have to get a clear response from the insurer by letter that they are stating their final position on the understanding that you will then be appealing to the ombudsman.
Hmmm, they must have given some grounds? Unfortunately, if you had ever been to the doctor with anything even vaguely neurological, they may cite that as evidence you or your doctor either knew, or should have known there was already a problem. Did you take out the policy that won’t pay after the one that did? If so, I’m assuming that in between taking out the two policies, you may have visited the doc about something MSish? Numbness? Visual problems? Tina
The below case seems to be the same as yours. In fact I think yours is better as one insurance company has paid out.
I don’t buy the idea that if more than two insurance companies are involved they pay out pro-rata. It might be right but morally you pay a premium for a certain pay out; that’s insurance end of story.
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 (unless you live in Scotland then it is precedence).
She was very lucky to get anything at all, since most policies don’t let you claim five years after diagnosis, because you “didn’t realise it was covered”.
It’s essential to check policies promptly.
I had only a three-month window to claim on mine. Which is shockingly little, really, when you consider that the claimant - by definition - must be “critically ill” at the time.
Thankfully, I did know I was insured, and got the wheels in motion as soon as I had a firm Dx. The company (Unum) were excellent about paying up.
But if I’d only realised three months and one day later, that I might have had a claim, it would already have been too late.
i would definatly take it to the insurance ombudsman. they will give you a dessision yes or no. their desission is final i think so thats as far as you can go with it.
I’ve just had my insurance company turn me down as I had been to the doctor twice before with altered sensation in my legs but as the doctor dismissed it as a poss trapped nerve, I didn’t think it was relevant to my insurance. I’m not sure what to do now as I thought my case was pretty straight forward. I want to appeal but it all depends on how much it will cost. Ash.
My critical illness insurance failed to pay out on my first claim because the neuro was dicking about giving a definitive diagnosis. I paid to see another neuro who gave a more definite diagnosis - along the lines of “it cannot be other than MS but prognosis unknown at this time”
I didn’t appeal the first desision just claimed again and the 2nd time they paid out.