Insurance Advice: Income Protection Claim Appeal after Year-Long Illness

pocc45

Hi everyone,

I wonder would anyone have advice for me in my current situation. It’s hard to summarise and I’ve missed some of the detail. 

I stopped working for a year starting last July because I was very ill. For 6 months my employer paid me my full wage and then I had to make a PHI claim to their insurer.  

The insurer took over 3 months to do their independent assessment by which time I’d already reached out to my employer to begin a phased return to work. They’re using the assessment as evidence that I had not been totally incapable of performing my occupation at the time of my claim. 

They say their independent assessment was done as quickly as possible because they had been waiting on a report from my GP. That feels very arbitrary to me as they already had a report from my treating specialist stating I was unable to perform my occupation, and the GP’s opinion isn’t even considered in an appeal - it’s only the treating specialist’s opinion that counts there. 

I am going to appeal the decision. However, it’ll cost me £375 to get a more detailed report from my treating specialist as to what factors exactly meant I couldn’t perform my occupation (this is what the insurer calls out as required in their appeals documentations). 

It all feels like total nonsense to me. Why would they have to wait for the GP report to do their assessment? Why didn’t they ask for more detail in the first place? Why is it on the sick person to chase people in this system? 

I’m wondering do I have any chance in an appeal? Is it worth getting the more detailed report? Should I just appeal with the existing report and then go to the ombudsman and save myself £375?

It’s worth noting I haven’t been perfect during the process. I was a bit late submitting my phi application because my employer only told me about it on the due date. I didn’t chase my GP to get the report in asap. But I was in bits sick. 

TL/DR: Insurer took 3 months to do an independent assessment and used it to deny my claim. What do?

NUTLEY BOY

Not legal advice. Just some general observations.

1. What does the insurance contract specify as the requirement to trigger provision of benefit ? Is it total incapacity for work or partial incapacity ? Is it incapacity for your specific work with your employer or any work ?
2. You carry the onus of proving your claim to the insurer.
3. The civil standard is the balance of probabilities i.e. it is at least 51% more likely to be correct than not.
4. Who is dealing with the insurers - you or the employer ? If it is the employers you do not know what they are communicating to the insurers. I would request copies of any communications your employers have had with the insurers about you - whether you get it or not is another matter. I am not suggesting impropriety but would be concerned more about the competence of some HR departments.
5. Despite what the insurers say in relation to medical evidence they must take account of all evidence and not dismiss the bit that is inconvenient to them. Paradoxically, in some matters, I have found that G.P.'s reports can actually be more helpful in providing a more rounded view of the patient, their illness and associated capacities.
6. The insurers have your medical evidence. Presumably, they actually referred it to their medical referee. Did they ever ask their medical adviser to examine you ? I would ask for "voluntary discovery" of their medical evidence on a reciprocal basis given that you have provided yours to them. Otherwise, you may be flying blind as to what their medical adviser has said about you some of which might be medically and factually right, wrong or both in parts.
7. Watch your time limit(s). Some insurance contracts provide that a claim may be deemed abandoned unless the matter is referred to arbitration within a specified time limit that runs from the date that the claim has been rejected.
8. Also, some contracts contain a Scott -v- Avery type condition which ousts the jurisdiction of the courts and mandates that all disputes must be referred to arbitration. If present in the policy under which you are claiming that might negative the involvement of the Ombudsman.

I hope that this shopping list does not drive you back to bed ! These are some of the matters to be thought about. Better minds will probably have other observations to make here.

If the quantum of your losses is significant it may be worth your while consulting a solicitor to run the rule over some of this as it can be extremely difficult for an unwell person to deal with big guns. If by chance you belong to a union see if they have panel solicitors who could assist you with this.

Best of luck......

deandean

I know of several people who have made claims under income protection policies. None of them were successful. Those policies seem to be a waste of money, practically a scam. But good look OP, the devil will be in the detail.

LimerickGray

https://www.boards.ie/discussion/comment/120935465#Comment_120935465

https://www.boards.ie/discussion/comment/120947737#Comment_120947737

I have made a successful claim under one of these policies but it was not recently. I am still in payment.

My employer was paying the policy so that made things even more difficult. I couldn’t even see the full policy terms - all I got was a HR blurb advertising the basics but not the particulars. I have never seen it

The insurance company won’t answer question as I am not the policyholder. They refer me to the company HR contact. HR make requests on my behalf. Odd.

I had a medical assessment in February 2023 organised by insurer. It wasn’t confrontational. Given the condition, the doctor was quite interested in talking rather than quizzing me. He had the letter dictated before I left. Before that, last medical was late 2019 but I suspect there may have been an impediment to examinations.

they don’t make it easy. Ask me more if you like.

One thing though. I’ve read it’s quite difficult to be made redundant for medical incapicacity if the employer is in contract with insurer for one of these schemes. Hopefully.