Can anyone offer me any advice please

My husband has had an income replacement policy with Pinnacle for many years. In July this year he had several heart attacts followed by heart surgery. At the time he was a self employed pulican on a joint lease with myself, however he was the personal licence holder. The business bank account was a joint account. We worked the business together and I also had a full time job. After the other half became ill (and hospitalised), I took over running the business with help from some friends and family. He had no input into the business at all - not even doing the accounts. After a few weeks, it became apparant that he would not be able physically to re commence working in the pub trade for many months, maybe even longer, we made the decision to resign our tenancy (with much regret) as it was too much for me to run on my own and not enough profit to employ anyone. In our tenancy agreement that we had to give 6 months notice to the brewery, I might add that the brewery were very supportive and found new tenants very quickly, however I had to continue keeping the pub open until 12 th December. My husband continued to pay his class 2 NI contributions during this period as advised by our accountant.

We sent a claim form into pinnacle, doctor completed medical evidence then pinnacle wrote to us requesting more info (as i wld have expected) They required bank statements invoices etc. No problem, I sent everything they requested and yesterday received a phone call advising they are declining the claim. They say as we have continued to work the business during aug to dec and there have been (obviously) credits into our bank account, that the claim has been declined.

I was obviously upset by this phone call and the advisor on the phone said she wld get a senior underwriter to call me later in the day.

The senior advisor did ring me and I explained everything about the circumstances. He said he would lodge an appeal for me but couldnt guarantee what the outcome would be. He said that they wld probably write back requesting more information and proof (of what I dont know).

I~ can understand here they are coming from , so I suggested that if it wouldnt be possible to allow the claim while he was still self employed would they at least allow it from when we had to give up the business, they advised that was not possible as it had to paid from the outset of the business or not at all.

I would appreciate any advice anybody could offer me on the way forward with this, as from his tone and manner I fully expect that they will once again deny the claim (I must add however, he was very sympathetic).

Sorry for this being such a long post but we desperately need this money and the uncertainty of our income is making my husband ill.

Regards and thank you so much in anticipation

Sue

please can anybody give me any advice thanks sue

Hi Sue,

To be Honest I am not too sure the Ins and Outs of these Income Replacement Policies.

I pressume you made a claim as soon as your Husband was Hospitalised ?,

I will PM you the names of a couple of folk on here who I think may be able to help you with this one.

Ian

Thanks Ian

No I didn't make the claim right away - too much personal stress at the time was just so unexpected - however I did make the claim as soon as I remembered he had the policy in force - but was in november. They have not disputed the time lapse in making the claim - just the fact that the bank account was still active and credits being paid in

thanks again

sue

Thanks Ian

No I didn't make the claim right away - too much personal stress at the time was just so unexpected - however I did make the claim as soon as I remembered he had the policy in force - but was in november. They have not disputed the time lapse in making the claim - just the fact that the bank account was still active and credits being paid in

thanks again

sue

Yes but it is a Joint bank account so they could expect payments to be goin in there

Ian

Hi Ian

yes it is a joint account and the tenancy agreement was in joint names - since he had his first heart attack end july he has been unable to work at all he had 11 heart attacks then heart surgery, the prognosis is good, however he will not be able to return to work in the pub trade or his previous employment as a lorry driver.

I ran the pub in the evening and our family helped throught the day he couldnt even do the accounts as the doc said would cause him too much stress

thanks

sue

Hi all!

Suecrill in reply to your post and PM:

To begin with I am very sorry to read about your husband's health problems and hope he continues to get better.

Anyway,let's se how we can help you here.

In order to possibly help you out I would need the written response of the refusal with reasons from Pinnacle word by word or you send a copy/copies of the letter/s to me to me to my e-mail address which I will PM you.

ALSO.....

Never believe anyone is sympathetic all they care about is lining their pockets and I am talking about the industry as a whole.

Anyway,enough of me ranting.

After I receive the letter from you I will give you my general view and backed up woith suggestions of the way forward.

FINALLY...

Do not worry as you are not alone on this forum.

Hi all!

Suecrill in reply to your post and PM:

To begin with I am very sorry to read about your husband's health problems and hope he continues to get better.

Anyway,let's se how we can help you here.

In order to possibly help you out I would need the written response of the refusal with reasons from Pinnacle word by word or you send a copy/copies of the letter/s to me to me to my e-mail address which I will PM you.

ALSO.....

Never believe anyone is sympathetic all they care about is lining their pockets and I am talking about the industry as a whole.

Anyway,enough of me ranting.

After I receive the letter from you I will give you my general view and backed up with suggestions/ideas regarding the way forward.

FINALLY...

Do not worry as you are not alone on this forum.

Suecrill,

I have just PMed you my e-mail address.

Hi

Thanks for replying. As soon as the letter arrives in the post I will e mail it to you. They read the letter to me over the phone on friday I have not received it yet. Thank you so much for your time.

regards

sue

Hi Nightmare4banks,

Hope you dont mind that I passed your name onto Sue.. I know you helped me in the past too. Thanks for getting back so quick for Sue too.

Ian

Hi Sue/Ian

I've had a quick read of the thread, and being honest, it really doesnt look like Pinnacle themselves know why they have declined the claim!

The fact the accounts are active and recieving credits have nothing to do with the claim itself, and should certainly not be affecting the claim outcome.

To add a little info, my partner is currently of sick with depression. She has a docters note, signed dated and a medical report written. We sent this to our lender (HSBC) where within 3 days they had authorised the claim.

Bear in mind the account is still very much active, and we are both being paid our normal salerys into it.

What I suggest is that you get the whole decline put in writting, and then take that to the OFT, or, if pinnacle are simply the underwriters for your bank, speak to your bank directly.

If you have any questions regarding the ins and outs of the policy, and you can show me a copy online (Or eMail it to me) I'll happily advise as much as I can.

-J

Hi

The letter recieved from Pinnacle states the following:

Dear Mr XXXXXX

Income Replacement Plan

Policy Number XXXXXXX

Claim Number XXXXXXXX

I write with reference to the above claim.

Unfortunately, I am not in a position to accept this claim for the reasons stated below:

Please be advised that you were still earning whilst being off sick.

I am sorry that I have been unable to be of assistance on this occasion. Should you disagree with my decision you may appeal to our Senior Administrator, who will review your claim in line with our internal appeals procedure. Please ensure that any evidence you have to support your appeal is made available for consideration.

Yours sicerely

Nicola Lampey

Claims Department

This decision has been made from the documents i sent to them, ie bank statements in joint names from Business Account, medical evidence, supporting letter outlining what I said in the first thread on this post, accountants name, etc.

Any advice gratefully received.

Many thanks to everyone trying to help me

Sue

Hi Pezboy

Thanks for your response, I have requested copy policy docs from Pinnacle who advise 5 working days for them to send. On receipt, I will pm you for your e mail addy. Thank you so m uch for taking the time to have a look at my problem.

thanks again

sue

Oh my god - another insurer trying to riggle out of paying - that letter of repudiation of your claim is appalling. In order to take the matter further, I suggest you write the following letter in response:-

Dear Sir/Madam

Complaint regarding Claim Number X123456

I refer to your correspondence dated 1st January 2006.

You have refused to deal with my husband's claim on the assumption that he was in receipt of earnings whilst he was unfit for work - this is NOT the case as it was myself who continued to work - not my husband.

Please explain, IN FULL, why you are unable to be of any financial assistance on this occasion and provide details of the specific exclusion in the terms and conditions policy upon where your decision has been made.

I trust your response will be that on behalf of your Chief Executive as I intend to take the matter further to the Financial Ombudsman Service if you remain of the view that you are unable to deal with my claim.

Nice reply Mooreda.. Im sure that will get the wind up them...

Good Luck Sue..

Ian

Oh my god - another insurer trying to riggle out of paying - that letter of repudiation of your claim is appalling. In order to take the matter further, I suggest you write the following letter in response:-

 

Dear Sir/Madam

 

Complaint regarding Claim Number X123456

 

I refer to your correspondence dated 1st January 2006.

 

You have refused to deal with my husband's claim on the assumption that he was in receipt of earnings whilst he was unfit for work - this is NOT the case as it was myself who continued to work - not my husband.

 

Please explain, IN FULL, why you are unable to be of any financial assistance on this occasion and provide details of the specific exclusion in the terms and conditions policy upon where your decision has been made.

 

I trust your response will be that on behalf of your Chief Executive as I intend to take the matter further to the Financial Ombudsman Service if you remain of the view that you are unable to deal with my claim.

Perfect

Thank you so much everyone for all your support an d help , we certainly need it at the moment - now how do i time this excellent reply - do i wait until they reply from my appeal or do I send it right away (and do I put a CAG sticket on the letter/ envelope ??????

My blonde moments are getting blonder and as for the senior moments - well !!!!!!

I cant even face tackling the debts etc yet - never mind one step at a time

thank you all so much

sue

I would send it off Now..Get the ball really Rolling so to speak.

Good Luck

Ian

Hi Ian

So I send it as it is - do I mention the appeal ? As they have told me they have put the appeal in motion. (I am not normally so indecisive but I am scared that I will mess the claim up)

thanks

Sue

Hi all!

Suecrill,in reply to your post and in my view:

1.Do you have any management accounts for the period in question i.e. the accounts that show actually if any drawings were taken out of the business plus expenses on a monthly basis starting from the offset of the time when your husband first started having his health problems?You need to ask your accountant this because you could have had no actual income for yourselves which could be confirmed - if needed by the accountant.

Just remember money put in a business account does not mean that any personal earnings were made.This is a VERY CRUCIAL point.This shows how brain dead these insurance claims big wigs are - or bloody crafty!

I will let the folks here be the judges of this!

2.Appeal the decision but do not ask alot of questions or tell them anymore about yourselves as you have already done this.

3.Let them explain their justification for not honouring the claim.In the event of them refusing,we will try and work around it.We will deal with it if needed further down the line.

By the way,the letter looks fine.

ALSO....

4.If they fail to play fair with you I would personally sue them for all the instalments that they have taken off of you backdated with interest at the County Court rate of 8% per annum plus an unquantified amount in compensation for leading you down the garden path.(Do not mention this AT ALL now - SAVE THE BEST FOR LAST!).

SORRY I HAVE NO FAITH IN THE OMBUDSMAN WHATSOEVER!!!

Anyway,this is my 2p's worth!

If you have any more questions,please feel free to ask.

Keep us posted.

All the best!

hi all

Thanks for your comments and advice.

In reply, Yes I do have management accounts, and without checking through them, I would guess they will show drawings from the business at approx £100 a week, maybe more some weeks. I was working in the pub seven nights a week, all day sat and sunday. My day would be get up at 6am clean the pub, approx 1-2 hours, go to work, take an hour off work in pm to visit hospital (my employers were wonderfully supportive), get back to the pub at 5.30pm and immediately go behind the bar and monday to thursday work until closing about 1am, friday until about 3 am. Then Saturday and Sunday clean in the morning and open bar at 12 noon and work until 3 am sat and 1 am sun.

The business was in joint names and this is what I had to do you cant just shut the pub because your partner is in hospital.

So, in summary, yes, there were drawings, however I consider for the hours I worked, surely they were justified???

Before my husbands ill health, I did work in the business, however only at weekends (and for fun!)lol

If I hadnt taken drawings, GMAC would have taken our house!!

Anyway, rant over, sorry everyone but I am so concerned about this claim, whether we sink or swim is dependant on it.

Regards

Sue

Hi everyone

Just a quick note to let you know I am going to chase the appeal by phone today and if no satisfactory reply is forthcoming, I will send suggested letter from earlier post.

regards

sue

Will be very Interesting to know what their response is Sue..

Ian

Hi - Just a quick update following my phone call to Pinnacle. They say they have written to us and for me to respond in writing on receipt. I will post here again when I have seen the comments on the letter, however from what they said on the phone is that I supposedly told them that the credits on the bank statement were nothing to do with the business (I needn't add that I did not say that at all). However I will reserve judgement until I receive the letter.

Catch you later Ian-thanks for your support

regards

sue