Scottish Provident CIC: Claim rejected

[MattyT]

Hi All,

Thanks for reading. We have a problem with at CIC claim we submitted on behalf of our daughter Lauren. She was born normally last October, a healthly and happy little girl. At 12 weeks our world was turned upside down, when doctors discovered that her liver was slightly enlarged, and that her muscle tone was not as good as it should have been. We endured months and months of clinical investigations, all came back normal. In May this year we were told that her liver was badly damaged, and that nothing could be done for her. We eventually submitted a claim against our CIC once her clinical presentations satisfied SPs definition of Liver Failure. In August we were told that her condition MAY have been caused by a genetic disorder (Mitochondrial DNA Depletion), although this has not been proved because a Liver Biopsy could not be taken. Lauren passed away 2 weeks ago from her liver failure, aged 11 months.

 

Today we received a letter from SP stating that they would not pay against the claim, referring back to an exclusion on 'Congenital defects'. We have never hid the fact

 

I guess my questions/feelings are:

1) Where does the burden of proof lie with cause of medical conditions? It seems as if SP have made a judgement based on a clinical inference, rather than on clinical fact

2) there is a chance that even if the disorder did cause her liver to fail, that her genetic mutation was the first ( there is no family history of this or any other disorder ),

 

I have made some early legal enquiries, but was wondering if anyone on here had any insight.

 

 

Thanks in advance.

 

Matt

Edited October 25, 2011 by MattyT

[MattyT]

**missing text from above*** Today we received a letter from SP stating that they would not pay against the claim, referring back to an exclusion on 'Congenital defects'. We have never hid the fact that there was a possibility that she had a genetic disorder, and feel like we have been very open and honest with SP.

Edited October 25, 2011 by MattyT

[honeybee13]

Hello Matt, welcome to CAG.

 

I'm so sorry for what you've been through, hope we can help a little.

 

I assume you mean Scot Prov's Critical Illness Cover? Before you start spending legal fees, I personally would pursue the normal procedures yourselves with Scot Prov. Have you spoken with the FSA's helpline? I believe they should be able to advise if you're likely to have a complaint. This could eventually lead to the financial ombudsman, which costs you nothing but would cost Scot Priv £500, I believe it is.

 

If you haven't already, you need to go through the complaints procedure with Scot Prov. They should send you a copy of it, or you may find it on their website. If you're not happy at the end of that, then you go to the ombudsman. It's a long process, but at no cost to you.

 

Both these organisations have websites you can check out.

 

Hopefully someone here will know if you can still take out a legal case if you don't like the ombudsman's decision.

 

My best, HB