In hospital for three months critical ill. What could possibly go wrong when it’s time to claim on my insurance?
We are told time and again to be proactive and to insure against all sorts of disasters from insuring our home, cars, pets, to ourselves. The UK insurance industry along with banks tries to get us to buy a wide range of protection insurance from PPI to life, critical illness and income protection. As we know, especially the banks who sold PPI at record rates sticking in on loans and products even without the customer knowing which led to the PPI scandal which is costing the industry billions of pounds a year.
So has the industry learnt a valuable lesson? NO it has not. The industry says their biggest problem in getting people to take out protection insurance is cost but when you talk to the public their number one concern is trust. What’s the point of paying for these policies? These policies never pay out anyway? To be fair the pay outs on protection policies has risen from the 80% mark to around 90% with Friendly Insurers paying out around the 98% mark with £6million a day paid out in claims. Here’s the sceptic in me… If you have 100,000 claims that means 10,000 people can be faced with a refused claim and if the industry never tells you how much in premiums it’s taking on a daily basis how can you come to a fair conclusion? So what happens when you take out a policy in good faith and your claim is refused? This:
In 2009 I was hospitalised with severe internal bleeding and a HB of 5 where I spent the next three months in three hospitals being treated like a lab rat. To cut a very long story short I was operated on without sedation, got a large PE on my lung due to being bedbound for so long, told incorrectly I had bowel cancer and epilepsy (treated for both) and put on enough powerful medication that you could have brought down an elephant. I suffered horrific withdrawals on discharge and because I was sent home without a life saving injection was admitted again in an emergency situation only 48hrs later. My next four months was spent at hospital 3 days a week as they fought to control the internal bleeding which was being made worse by the treatment for the clot which resulted in my blood being made thinner which in turn made me bleed more.
Finally after blacking out in January 2010 I was seen by another specialist who stopped the clot treatment and finally I could have an operation to help stop the bleeding. The bleeding slowed but I was still quite ill and with the added stress of being unable work along with my wife losing her job due to the recession we had to live on £62.50 JSW along with food and essentials being bought by our families. I like to think I was prudent in taking out protection insurance and we started our claim against insurance giant Scottish Provident in September 2009 as I was too ill to start it whilst in hospital and as you can imagine we had other things on our minds.
I had been sold what is called a “task based” protection policy which meant I had to be unable to do a set number of tasks to get a pay out. These tasks range from 6-8 and you have to be unable to do between 2-3 to get a pay out but consist mainly of; can you hold a pen in either hand, can you communicate in a way to be understood, walk 200 metres without stopping or being in serious pain, can you hear in a quiet room and read 16 point print all with the help of others or aids? Some might be thinking these sound very similar to the tests currently being used to see if people should be receiving disability state benefits and you would be correct. These policy definitions were taken from the assessment of benefits years ago and are used by insurers for policyholders they deemed to be “high risk” to insure against the inability to do their own job. If you do any form of manual work, e.g. driving even if it’s just a small percentage of your job the chances are you have a “task based” policy or to give its correct name Activities of Daily Living (ADL) or Activities of Daily Working (ADW).
So in December 2009 Scottish Provident refused my claim because they said I had not experienced any restrictions through my illness or medication even though I was in hospital for three months. We asked to see the reports which left us dumbfounded. The forms were in 3 parts. The first part was about the policyholder, second was looking for non disclosure and if I had caused my illness with the last part asking about my restrictions to six set tasks. Now this is where it got interesting as the form asks for the policyholders current restrictions to the set tasks even though some consultants had not seen me for four months. These consultants said “we presume he has returned to work or not seen from discharge so don’t know current health condition but after this length of time we would say he should have recovered”.
My GP on the other hand knew different and said I was still restricted, having frequent emergency admissions to hospital and did not expect a full recovery until March 2010 as I was also being treated for a blood clot. This was also supported by a private consultant but Scottish Provident said they could ignore this evidence because the consultants in the hospital were more qualified to comment. Back and forth my case went in the internal quagmire of Scottish Provident’s claim handling teams so we went to the Financial Ombudsman Service. A lovely lady helped us through and I told her the evidence was wrong so she suggested we got the correct evidence and then send it to her. We thought this would be easy but the NHS put up brick wall after brick wall as they knew they had totally mishandled my care. It took us to make an official complaint against both Trusts and a face to face meeting before we got the evidence we needed as their approach was that it was not in their interests to comment. Armed with new evidence we went back to the FOS only to be told they could not use this evidence as it was not available to Scottish Provident when they refused my claim even though the new evidence supported my claim in full. They returned my claim to the insurer and asked them to assess my claim again based on the new supporting evidence but Scottish Provident just kept refusing my claim.