Critical Illness claim rejected

[Heart_stopper]

Anyone any experience in challenging a critical illness rejection? The insurer is claiming I was reckless in completing the form.

Currently with the Ombudsman who believes It was careless mirepresentation as opposed to deliberate or wreckless.

But have just replied to the ombudsman as it too appears to have made an error in reviewing and potentially misinterpreted some of the questions and information provided in response.

The ombudsman commented...

1. I answered No to the question 'am I waiting for routine blood pressure or blood tests?'.

The ombudsman noted I was waiting for the 24 hour BP monitoring to be carried out - however this was not correct.

I wasn't waiting for any tests. These had been carried out (routine blood test about 2 months before the application (according to my records) and the 24 hour tape over 2 weeks before at my local surgery GP surgery).

This is incorrect detail used to make a decision.

2. How long was my last BP reading at my GP or hospital. I couldn't remember the precise date/time period. (I wrote within last 6 months to be on safe side). They told me it was 2 months.

3. Did I know the result of my last BP reading taken by a doctor or nurse at GP Surgery or Hospital)

I answered YES.

4. Please tell us the latest BP reading at GP or Hospital or provided by you.

As the question allows, I selected a reading provided by me to the nurse (as I have my own device which I bring to my appointments and regularly compare readings). The nurse usually takes multiple readings as I suffer 'white coat syndrome'.

I'm not sure how many of the readings are recorded by the nurse. I assumed all of them. But the insurance company has fixated on 1 single reading from my records and it's slightly higher than the reading I inserted.

My reading was 145/80

Against 150/90.

Though the question allowed me to answer with a reading provided by me.

I was upfront on the application that I was on medication for high blood pressure and i mentioned i took routine blood tests and BP as part of the treatment.

I don't believe I have been careless and my answers are reasonable and accurate.

The ombudman also noted that I had given a particularly credible explanation of the circumstances leading to the application.

I must also note, the application was carried out via telephone by an agent and all the questions were discussed as the agent completed the application form based on my replies.

The insurer did not review the telephone conversation with the agent and based its decision on text and boxes ticked.

Any thoughts, questions and opinions would be greatly appreciated.

[Wooodsie]

You need to get a copy of the tape for the voice application. Then get this transcribed. You can, I believe, appeal the ombudsman decision. But before you do, I would suggest you record in print a full statement of arguments.

[Fministry]

I think it is difficult, or near impossible to remember dates; times; readings of tests; medication changes; etc

This is why it would be much better all round for a customer to sign a disclaimer to say the insurance company can apply to see your medical record. That way the insurance company can’t claim someone is withholding information or deliberately misleading them.

It seems that you answered to the best of your recollection and for that they are using it against you by trying to wriggle out of covering you.

I hope it is resolved in your favour. I think the whole process needs an overhaul.

[Gymlover1979]

which company is this? I’m very surprised they are bothered by what you wrote/said, and instead not just referring to your medical records or reports from the HCP. They may reject because of your history, but to reject because your recollection of events on a form is slightly out seems very harsh. Definitely challenge them. Sorry I have no experience of this. There are companies that will do it on your behalf, but they take a commission…

[Heart_stopper in reply to Gymlover1979]

The medical history of high blood pressure was declared. L&G saying the BP reading I put on the form didn't match the medical records... I noted 145/80 while nurse recorded 150/90. Both are in the same range of Stage 1 hypertension. There are usually a few readings taken and I also bring my own device (exact model recommended by the nurse for me to buy) and share readings. The question on the application form asks me to provide the latest reading taken at or provided by me at GP surgery. I wrote the number provided by me to the nurse. I assumed all readings were recorded - the reading provided by me and all readings taken by the nurse. It seems strange that L&G have only used 150/90. For this also to be deemed as careless is a bit strange - considering again that both readings are in the same group as 'stage 1 hypertension' and I had already declared this on the application form.

[Kkarlak]

I was stitched up by them (in my view )

My policy states that to claim multiple stents must be fitted and they do cover heart attack. My heart attack was not a situation where I went down and ambulance called, I went into Hospital after feeling unwell, where blood tests showed high levels, 6 days later 2 stents fitted.

It was only afterwards, I thought about my critical cover, expecting them to find a way out of paying. Well, they came back and said it was covered, but I would not get the new higher rate that I had paid to go up to. I doubled my pay out cover 2 years before.

The reason was that they said I already had hypertension (which is debateable - I was on a very low dose amnedopoline for stress related issues with blood pressure )and because of that, any increase in my cover is "on hold" for 2 years. Now my 2 year anniversary of upping cover, I was literally short of by 8 hours !! If I had gone into Hospital at midnight that day, I would have been covered. I appealed don good will grounds for the 8 hours, also that I was not technically diagnosed with hypertension, but they wouldn't budge. I also pointed out the stents were fitted 6 days after the 2 year window, but they said they don't count that, they just look at when I went into Hospital, which is convenient for them.

I honestly believe they dig and dig until they can find a reason either to now pay or reduce the pay. There must have been a collective cheer in their office when they found this dubious get out. Ombudsman were useless as well.

This is one of the, if not the biggest insurance providers in the UK and is done through my company scheme that I pay for. In my mind they basically took the higher premium I was paying for 2 years, then looked for a reason not to pay me the £25K difference. Oh and for good measure I am now told I am not covered for further heart/blood issues.

Probably all within their t&c's, but shoddy from their point of view. It wasn't like I was trying to diddle anyone, which I guess they are looking for with pre-existing conditions etc. I guess I was hoping for some common sense or compassion from an insurance company, that was my first mistake.. 😆😆😆 . I am £25K down on what I should have got, but at least they have saved that money for themselves........

Don't even ask me about our ongoing 6 month Home insurance claim with Churchill insurance for a water leak we had in February. Very quick to take your money and all that.

[Survivor1952 in reply to Kkarlak]

Good luck with Churchill, they'll try anything and everything to avoid a claim. Worst insurer I've ever had the misfortune to deal with.

[Kkarlak in reply to Survivor1952]

Awful experience with them, they just sub everything out. Even got AXA involved somehow. Will be the last time we use them.. Apparently they are part of direct line.

[Heart_stopper in reply to Kkarlak]

Mine is with L&G. Absolute nightmare. Took them close to a year to investigate and decline. Being given incorrect updates and chasing my GP surgery to send on details when it had been sent and L&G had to info. Mistake after mistake and failure to give updates and no one did call backs when promised. Supposed to investigate thoroughly, but didn't request the recording of the call with the agent 'Reassured'. Despite having a complaint settled in my favour and all its failings highlighted... L&G continued to drag its feet for another few months (seems it learnt nothing) from the original findings.

[Turnipgirl in reply to Heart_stopper]

I applied to work at l and g and I am waiting to hear back from them after my interview on Monday just gone!

If I don't get in I won't be heartbroken over it!

[tonylongman]

My wife and I seem to have taken up disputing insurance claims as a hobby! On many occasions we have been declined cover on a whole variety of claims and we usually seek a referral to the ombudsman as a matter of course. We have often found the initial response from the ombudsman as poor as the first response has typically been prepared by someone with limited legal knowledge, however when the complaint is then referred for a second opinion we have usually been successful (it helps that my wife is a lawyer!). Good luck with your claim and don't be put off, a long slog but likely worth it in the end!

[Heart_stopper in reply to tonylongman]

Finding that too with the initial response from the Ombudsman. A few glaring errors and contradictions. Awaiting the guy's response to my initial queries before taking to Ombudsman 2.

[catherine1712]

i had the same things with Zurich Insurance.

[Heart_stopper in reply to catherine1712]

How did you resolve or are you still contesting?

[Viwestyn]

I’ve had a similar issue when my insurance company tried to deny a claim based on "careless" information, even though I was upfront and accurate. After submitting the case to the Ombudsman, I realized some details in their review were misinterpreted too. In my case, I found that the insurer focused on minor discrepancies that weren’t material to the claim, just like in your situation with the BP readings.

If it continues to drag on, I’d recommend reaching out to a professional like Tulsa Bad Faith Insurance Attorneys norwoodlegal.com/tulsa-bad-... helped me navigate a situation where the insurer wasn’t playing fair.

[Heart_stopper in reply to Viwestyn]

Were you succesful in appealing?