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Critical Insurance Claim - criteria question

Hi everyone

I know this topic pops up every now and again and some of you have successfully made a claim on your insurance policies. I was wondering if anybody had a similar qualifying criteria as what I have on my policy and what was the outcome. I am insured with Friends Life and was going to make a claim a year ago, but as I did not have a definite diagnosis back then, only probable MS. I had to wait until I was given one.

The wording of the policy is as follows:

Multiple Sclerosis - with persisting symptoms. A definite diagnosis of Multiple Sclerosis by a consultant neurologist. There must be clinical impairment of motor sensory function, which must have persisted for a continuous period of at least three months.

I have been given a diagnosis of relapsing MS, does this not qualify as persisting symptoms? As far as clinical impairment of motor sensory function, would the fact that previous relapse/s which still causes numbness/ pain from time to time be a qualifying factor?

Thanks for your input

Have you explained the situation to the insurer?

I often think of any insurance provider as ‘slippery’ and expect them to try their utmost to avoid payouts wherever they can !

Back when I was considered RRMS, I had periods when there were major physical issues, and periods when I experienced no problems at all. There was no anticipating which state would be in effect, and for how long …until it actually happened.

From an insurance point of view (playing devil’s advocate), would numbness / pain count as ‘debilitating’ ?

Only your insurers could answer this.

Good luck,

Dom

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Hi number08

My policy was with General Accident and the wording was very similar indeed especially the clinical impairment which must have persisted for a continuous period of three months.

I was a little worried at this because neurologists tend to make light of things and I had made a pretty good recovery from my two relapses in the first year. However, I did have some lingering symptoms but didn’t really harp on about them to my neurologist so was worried that his report may have said I was not affected.

I also claimed a year after diagnosis simply because I had forgotten all about my CHI plan and only found it when I was clearing out some paperwork. I had originally taken out critical health insurance because there is a history of heart disease in the family and never thought I would get something else wrong with me.

As it turned out, all the company needed to know was that I had been diagnosed. MS, by its very nature, means you have lifelong symptoms so my insurers paid out once they had checked with my GPs that there was no hint of MS before my first symptoms and once my neurologist had confirmed the diagnosis. I am also RRMS but that does not mean that we have no symptoms between relapses as you so rightly point out.

Good luck.

Tracey x

Hi Dom/ Tracey thanks for your comments about this. I have not mentioned anything to the insurer as the policy is through work and they didn’t want me to Put in a claim until the definite diagnosis was made. The claim form already has me stumped as it asks for the date of the First symptoms, trouble is my neuro has said that my clinical history Suggests symptoms dating back to 2009. I think I am going to put last Year and put a note that the symptoms could have been as long ago as 2009 according to my neuro. I an dubious as to whether they will pay out. I think it’s only a small Amount I am covered for through work and I don’t have a mortgage I rent My house so no mortgage cover here. Would be interesting to hear other forum users stories about claims.

I had a similar clause in mine, and expected it to be cited as grounds to refuse the claim, but in fact, there was no such problem. I think they were very well aware of the fluctuating nature of RRMS, and knew that if they applied that clause too literally, some people would never be able to claim. (I had a three month claims window from diagnosis, as well, so I couldn’t wait for it to “get permanent”, and then claim).

Although I did not consider myself to have “ongoing impairment” at the time of claiming (it was nearly a year from “peak” symptoms), some notes from a neuro physio I’d seen privately (but not in connection with the claim) were in my GP’s file, and indicated I had some very minor residual impairment I’d not even been conscious of, such as: “weak left ankle”.

So the evidential threshold seems quite low - you do NOT have to prove significant ongoing disability (not unless it says so).

Tina

Hi Number08,

My experience of Critical Illness, is that they are ok with taking your money, but will find anything wrong with your medical history and will say your have not disclosed properly or failed to inform them of your medical condition, correctly.

My anger comes from being sold a Critical Illness policy for some years, thinking everything was covered and then finding out that I had taken a week off work (Less than 5 days -Doctors certificate) for FLU. Because I did not disclose this, they would not pay out !!

They promise you the world when they want your money, but it is a fight to get them to pay up !!!

Regards, Andy

Hi Number08,

had 2 policies one with Scottish widows and one with Santander, no problem on either they both just wrote to my go and neuro for confirmation of dx of RRMS, dealt with both very quickly and nice to know we have a little nest egg if needs be, let us know how you get on.

Sue

welshpony did you not consider taking your claim further to the insurance ombudsman? its a free service i believe and they may get your claim sorted for you

Hi Dom

Thanks for playing devils advocate ,I just re read part of your post and was wondering about your quotation of the word “debilitating”. Does the part of the qualifying criteria I listed actually mean “debilitating” then?

Multiple Sclerosis - with persisting symptoms. A definite diagnosis of Multiple Sclerosis by a consultant neurologist. There must be clinical impairment of motor sensory function, which must have persisted for a continuous period of at least three months.

What would qualify as an example of “clinical impairment of motor sensory function”?

Interestingly from Tina’s comments, I think that I am in a similar situation, I don’t feel that I am ill, just have some bad days where parts of my body don’t work properly. I do only have a three month window to put the claim in though, and not really in a position to wait for things to become permanent.

I guess I just need to put the claim in and see what happens.

Cheers

If it doesn’t use the word “debilitating”, then it doesn’t have to be so. Impairment can be ever so subtle - you do not have to consider yourself “disabled”, neither does anyone else.

However, “motor sensory function” does not seem to make much sense to me, as a phrase. MS can cause motor problems, or sensory, or both. But as they are two different types of function, I’ve no idea what: “motor sensory” means. It’s a bit like saying: “visual walking difficulties” - er…Duh? Would that mean: “visual” OR “walking”, or both? It is my hope that by lumping them together like this, they actually mean either, and you do not have to prove both.

Having said that, motor impairment is a lot easier to prove. It should not be that hard to demonstrate you can’t walk, for example - and not that easy to fake. However, who else, apart from you, knows you have a pain, or a numb foot (sensory)? I know they can do the pinprick test, and all that (Oh how I loved it - NOT!) But as it’s not sharp enough to make you yelp, I suppose anyone so minded could pretend not to have felt it, when they did.

I think you are right that all you can do is get on and claim it - give as much supporting evidence as possible, and hope for the best. There is certainly no point in NOT claiming, just in case it’s unsuccessful. As long as you’ve been honest, there is nothing to lose by trying.

Mine was through work, at the time, which I had a bit of a niggle about, as the claims process meant you HAD to go through HR - so if you wanted the money, you could not exercise your right of not telling work about your diagnosis. It’s very unlikely I’d have done that anyway, as I thought having it on record would protect me, rather than the contrary - BUT the claims process should have been confidential between me and the insurer - not via HR, just in case I didn’t want them to know,

Anyway, the arrangement did at least let me speak to the HR lady, and I specifically asked her about that clause. She replied: “Obviously, I can’t go into details, but we’ve had other MS claims, and it hasn’t been a problem - they understand the nature of it.”

And so it turned out.

I ticked the box that said I wanted to see any report provided by my neuro, before it went off to them, just in case there was anything I wanted to take issue with. I was particularly concerned, like you, that he might say I had symptoms stretching back years, which, with hindsight, I did. However, there was nothing, at the time, that was obviously neurological, or that would lead any but the most paranoid of people to think it was anything as serious as MS. I’d had a few years of aches and pains, and feeling generally older than my years, but nothing more dramatic than that.

In the event, I never did see the neuro’s report, so I can only assume they never requested one. Copies of my diagnosis letter and the results of all the tests that led to it were in my GP’s file, so I think they accepted it was an “open and shut” case, and didn’t even want to speak to the neuro. Which was great as far as getting the money was concerned, but just a little bit of a shock they didn’t want to argue or ask any questions, as I’d been half-hoping they’d raise the possibility it might have been a mistake. When someone with every motive for quibbling says: “Yeah, that’s fine, you’ve clearly got MS”, it brings it home to you you really must have, and that nobody’s going to come along and apologise for the mistake.

I never seriously doubted my diagnosis, as it was the first thing anybody had said that really had the ring of truth about it - after years of being told my problems were all down to having one leg longer than the other, or even: “wearing silly shoes” (which I never had). But I suppose we all get that feeling of: “Maybe I’ll wake up and it won’t be real”, to some extent.

Anyway - sorry for the long ramble. Just get on and claim it - it might not be the problem you think. The only issue I had was they put the entire sum in my current account while I was on holiday in Turkey, without telling me they were going to settle! I didn’t find out until I got home, and saw an abnormally large amount of money in there. So thank goodness I didn’t get my bag snatched or card skimmed while I was abroad, as somebody could have cleaned out the whole lot, and I’d have been none the wiser it was ever there. Never did get a letter confirming - just the money. That will be interesting if the tax people ever want proof where it came from, because I’ve got nothing!

Tina

x

Just an update for anyone interested.

Well my claim has been submitted and I have now seen my GPs answers to the insurance companies questions towards my health and wellbeing. What has surprised me (maybe not as its always happening) is my GPs attitude towards how MS affects me on a daily basis.

One of the questions being asked is what are the abnormalities that your patient has experienced. To which my GP has listed five different things and stating that these abnormalities have been present since 2011. He has not mentioned at least two different parts of my body which is affected. The next question asks if these abnormalities been present continuously? and the GP has answered NO!

Now don’t get me wrong, I would never class myself as having any debilitating issues at present, I feel very lucky, but I do and still have issues with numbness in my arms, fingers and feet. I also find it pretty difficult to walk very far as I suffer from tightness in my right leg which prevents me from standing on my leg for any period of time. This started over a year ago and has not improved since. I would say that this would warrant an answer of yes to that question alone.

Just because I don’t continually visit my GP for everything which causes me health issues, then I feel that my GP presumes that I am unaffected. It was due to my last neurologist who constantly dismissed everything which I reported as being MS related that it took me so long to get a diagnosis and started on treatment.

I don’t visit my GP very often as I don’t have time! I have to work and taking time off continuously will only lead to my employment being terminated. Don’t even get me started about trying to book an appointment in the first place…

I have booked an appointment to see and discuss these answers with him and I think I am going to have a bit of a pop at him if I am honest. He doesn’t know me very well, perhaps he has seen me twice over the last year and one of those times was for a private referral to a neurologist, which no doubt he got a back hander.

The best part is - within my notes, which were about to be sent to the insurance company were another patients records listing a medical condition which he had been diagnosed with. The way the report was compiled and bound together, hid this other patients name and it did look as though It was part of my medical record. The fact his notes were mixed up with mine is a little disturbing and seriously breaches patient confidentiality.

Anyway rant over for now, I have a three hour journey to get to work today. I will update this again once I have seen my GP if anybody is interested.

so what has happened since, number08? i am interested as i am on the brink of putting in my critical illness claim, and am concerned with how it may be received.

hope you don’t mind me asking…

Hi number08, I need to do the same as you and I’m worries that my doctors may do exactly the same as yours did…!!! Please may I ask how your claim ended up? Surely it would be better for them to talk to the neuro surgeon rather tahn the doctor!!? Any help you can give me would be greatly appreciated. Thanks in advance.

Please confirm with the Neurologisst the diagnosis. Most policies state you must show symptoms for 6 months. You probably qualify now but if not it’s only time.

You may have to fight your corner; don’t give up; see below; different circumstances but just to show you must not take no for an answer.

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