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

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......

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.