Help with critical illness claim

[master woody]

Unum have said that the comunication from them stating i had cover was an " over sight" but are considering the claim on a good will gesture!

 

As for the the rejection on medical groups, thay have rejected as my wife made a "full recovery" but admit she had a stroke resulting in death of brain tissue.

 

The policy states section 6.1.13 " Death of brain tissue due to inadequate blood supply or heamorrhage within the skull resulting in permanent neurological deficit with persisting clinical symptoms.

 

 

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[master woody]

Hi All

 

I've had the final decision from Unum, Makes interesting reading! I think the next step is the FOS as my wife clearly had a stroke and is suffering from permanent symptoms

 

Any other ideas?

 

 

http://img13.imageshack.us/img13/206/pic1dap.jpg

 

 

http://img36.imageshack.us/img36/4550/pic2lws.jpg

 

http://yfrog.com/0dpic1dapjx

Edited August 6, 2009 by master woody

[eddieee]

I have been down the path of having a claim stopped by an insurance company and having to go to the FOS. The adjudicator upheld my complaint but the insurance company didn't except the decision so an Ombudsman decision was asked for and the Ombudsman upheld my complaint and ruled that the insurance company should continue to pay out. This process took a year and you should expect a similar length of time to complete this complaint.

 

You now have six months from the date of the final decision to lodge your complaint with the FOS. You can download the form from there web site. You shouldn't need any help in filling this out, just use plain English and your own words and include any documentation you have on the matter.

 

Funny thing is, the insurance company sent the final decision to my company (they have to send it to the policyholder) and my company seem to sit on it for a month. Personally I think that under Contracts (Third Party Rights) Act 1999, you have the right to be informed directly of anything relating to you if you are a named member of the contract i.e named on the policy, not just the policyholder.

 

You should also send Unum a request for all data held by them under the Data Protection Act along with a cheque for £10.00, there is a template on this site for that. What you will get will be lots of paper, some of which is their internal communications on this matter. You can study this and see if you find any inconsistencies in their process and highlight it to the FOS. You do not have to do this before filling in the complaint form, you can update them later on. They are very good at acknowledging your correspondence.

 

Did Unum perform any medical examination before they first denied the claim. If they did the examination afterwards as part of your complaint, this will work against them as it did in my case, and was highlighted my the Ombudsman.

 

Good luck.

Edited August 13, 2009 by eddieee

[master woody]

Thanks eddieee I'm now preparing my FOS now, do you think it's worth seeing a solicitor to help me prepare the complaint?

[eddieee]

I think that the FOS would want to hear your compliant in your own words. If you know which clause in the policy you are challenging then I don't see that a solicitor is needed. Really if a solicitor was needed they would have to have some specialty in medical cases and insurance and then would only be needed if you didn't know how to make a challenge against the policy. I can't see the point in employing one just to word your compliant in a better way.

 

The FOS will look at your compliant and compare it with the policy. They may ask your wife's doctors for their opinion. They may possible ask for an Independent Medical Examination although I think this only happens in complex medical problems. They should be able to rely on your wife's doctors opinions. If the insurance company has not conducted a medical examination then the adjudicator has a simpler job as they only have to look at one lot of medical evidence.

 

All of this is done without any meetings, so you won't have to argue your point face to face with the adjudicator or the insurance company.

 

The compliant form gives the FOS the right to access your wife's case file with the insurance company and her medical records.