Help Required on my Critical Illness Claim- Non disclosure Issue raised

[Gavin0259]

Hi,

 

I am hoping that someone can give me some advice with regards to my claim. I have a critical illness policy with friends life and in september whilst away with my family I suffered and unexpected heart attack and cardiac arrest in spain. Once back in the UK and feeling a little better I opened my critical illness claim, medical details were a struggle as it happened in Spain so required them documents and had to have the translated etc. Now that they have most although still said they did not have my ecg results, they called and said that looking at my medical report my docter has confirmed that we have a strong history of heart condition in the family with my mother having a bypass at 48 and my brother suffering a heartattack at 28.

 

I disclosed the fact of the heart condition of my mother on the forms however I did not declare my brother which at the time of completing my form I was never aware and only when they called I was made aware. We do not really talk and my brother is very much a private person and i dont think he had told anyone of his condition and to be honest whenever I have seen him has looked fine and is 40 now. When I have been for regular tests for my cholestrol the docter has said we need to keep an eye on it due to family history but never ever indicated my brother had any issues.

 

I have now been told that they could cancel my policy as i did not declare this information and had I the underwriters may not have given the policy or the premium would have been different. They said they will make a decision in the next week and may need to write to my docter again possibly to ask if I would have knew. I confirmed that I genuinely did not know and was open about my mother and would have been about my brother if I was aware. Reading the internet their are so many stories of how they look to find any loop not to pay and this seems to be something so am not very confident at this point.

 

I would really appreciate some advice and what steps I could take if they decline my claim, or what I could do in the meantime, I still have not spoke to my brother about this as I do not want him to know i do know as he obviously kept this quiet for his reasons.

 

Thanks

 

Gavin

[citizenB]

I am sure that if you had known of your brothers condition and disclosed it, it would have made no difference to them providing you with a policy, although very likely at increased premiums. However, they do seem to be looking to use this as a way not to pay out.

 

Your doctor would not have been permitted to tell you about your brothers health either.

 

Families dont talk that is fact - I hadnt spoken to two of my siblings in years, so would have no idea of their health ?

 

I am sure others with more knowledge of this industry, will look in and advise further.

[Gavin0259]

Hi

 

Thanks for the reply and they were my thoughts that they would have still given the policy, at the time of completing the form I done so to the best of my knowledge. I have not told many of my condition and due to mortgage comitments and children I had to go back to work quite quick so many have no idea the seriouness of the attach I had or that I had an attack which I have kept personal with my wife. So i can understand why my brother never said anything especially if he had it at 28.

[JPM347]

Hi,

 

There seems to be two slightly different issues emerging here;

1) the company are trying to find was not to pay out in respect of your claim

2) they are then saying they will cancel/not reinsure you in the future.

 

In respect of (1) you honestly disclosed all information that you knew at the time of taking out the insurance. The insurance company accepted you on that basis. Your insurance is valid and so is your claim. Any matters raised after the fact, unless it can be shown that you acted dishonestly, will be irrelevant.

In respect of (2) as the company are providing a service/product it is their prerogative to withdraw that at any stage, this will not affect the validity of your prior claim for when you were insured.

 

A well worded letter from the Citizens Advice Bureau should do the trick.

[Gavin0259]

Hi,

 

Regarding 1, i understand that I have declared openly my mother and had no idea about my brother so was honest as could be. However you are always sceptical with insurance companies of how far they will go to not pay.

 

Regarding 2 i am on the understanding that should they pay the policy will cease. However he said that in-light of this information they can cancel the policy from the offset and pay me what ever I had paid in premiums because if they had known about my brother the underwriters would have made a different decision at the time.

 

What angle would I ask the citizens advice bureau to word the letter and I assume do this once I get the decision, which At the moment I am not optimistic about.

[citizenB]

All you can do is persist with the fact that

 

a) You disclosed information of which you had knowledge.

b) You were not aware of your brother's illness - and your GP certainly never disclosed htis information to you - indeed - your brother would have been extremely angry and the GP in serious trouble had he done so.

c) That you believe you have a valid claim, which you will pursue via other means.. ombudsman, court if they continue with their implied refusal of your claim.

[honeybee13]

Hello there.

 

To add to what CB has said, I believe you need to have exhaused the company's internal complaints procedure first. If you they have not resolved matters to your satisfaction after 2 months, you can go to the ombudsman.

 

Make sure you keep a good paper trail in case you need it.

 

My best, HB

[Gavin0259]

I have spoke to my financial advisor who i went through for the policy, he was shocked at the stance they are taking and has said he will help with the issue and write to various people.

 

So I would need to take it up with Friends Life internal disputes initially and if they still do not overturn should I then seek county court or ombudsman. Again on the grounds that the information I supplied was to be honest at the time of completing the form and did not intentionally with hold anything.

 

Thanks

[unclebulgaria67]

I have spoke to my financial advisor who i went through for the policy, he was shocked at the stance they are taking and has said he will help with the issue and write to various people.

 

So I would need to take it up with Friends Life internal disputes initially and if they still do not overturn should I then seek county court or ombudsman. Again on the grounds that the information I supplied was to be honest at the time of completing the form and did not intentionally with hold anything.

 

Thanks

 

Once there is reason for a complaint to FL, you then make this complaint in writing and FL are allowed 2 months to try to resolve with you, before you can involve the FOS. In a case like this, where it is potentially complicated/long winded, I am not sure the FOS would be the best avenue to take, as it not uncommon for them to take 2 years to decide. Therefore you may be better off going down the legal route and getting a Solicitor that deals with such cases. The potential legal costs may be high, so you would need to look at what you could do to reduce/eliminate your risk. e.g fixed fee arrangement, no win no fee, legal expenses Insurance ( do you have any legal expenses Insurance, if not there may be ATE policies available. ).

 

But I would think that FL will come to a sensible decision and deal with the claim as normal. I cannot see that you would be expected to disclose a Brothers health condition, that he had not made you aware of.

[Gavin0259]

Thanks I am hoping they come to a sensible decision and guess I will find out in the next week. if its declined my first port of call will be to write a letter to FL complaints to dispute the decision. Can you please advise what I would need to raise and write in the letter.

 

I have since spoken to my GP regarding this and he said that he is aware that I never knew and they should not have told me as its confidential if my brother does not want anyone to know and in his report he highlighted the family history as they requested. He said if they write to him he will confirm that this was never discussed with me and I would not of had any idea if my brother had not told me.

 

is their anything I need to be aware of or look out for that FL will try to make out that I would have known.

[Michael Browne]

Can you see a pattern emerging?:

 

http://www.thisismoney.co.uk/money/news/article-2243869/Friends-Life-refused-pay-100k-life-critical-illness-unrelated-conditions.html

[unclebulgaria67]

Thanks I am hoping they come to a sensible decision and guess I will find out in the next week. if its declined my first port of call will be to write a letter to FL complaints to dispute the decision. Can you please advise what I would need to raise and write in the letter.

 

I have since spoken to my GP regarding this and he said that he is aware that I never knew and they should not have told me as its confidential if my brother does not want anyone to know and in his report he highlighted the family history as they requested. He said if they write to him he will confirm that this was never discussed with me and I would not of had any idea if my brother had not told me.

 

is their anything I need to be aware of or look out for that FL will try to make out that I would have known.

 

You would keep it simple. Your GP can confirm that you were not made aware of your Brother medical issues and that you are willing to provide testimony in court that your Brother never told you about it. You don't need to write long complicated letters, as it is up to FL to make their case, if they want to avoid your claim. I think it will be very difficult for them to do so.

 

Don't be pessimistic at this stage. Wait to see what FL do and then post back.

[Gavin0259]

Thanks I will wait and see what they come back with and post for your advice. Fingers crossed they payout.

[Gavin0259]

Hi,

 

Just wanted to update on my claim and get your views and advice as to the steps to take.

 

I have been going back and forth with FL with them contacting my GP for information, they wanted my medical records from the time my brother was diagnosed. Two years after he was I had an appointment for hayfever and cholesteral check and in the notes it said family history, which I have noted about my mother in the application form, it does not specify my brother and I have confirmed to them I have never discussed or known of his condition.

 

Everytime I talk to the claim assessor, he then needs to get more information, now my full medical records which previously he has already looked through as my cholestrol was 7 and thats high he says yet my GP said when I seen him that on all the notes and any checks I have had and the last one 2months prior to my heart attack the doctor seen has put me down as very low risk. At any time no doctor advised or said I was at risk and need medication and so was never on any previous.

 

Its funny that when ever he talks he says that if I had to make a decision today it would not be good for me and that the policy would be cancelled and so his contacting the GP to get more information to clarify things he has not. I thought that the whole point of the assessor is that he wants to not pay me so why is he doing me a favour to get information from the docter that would help my case? Or is it that he is still looking for something that they can use to turn me down.

 

The only thing I can see they are trying not pay on is that I did not disclose my brother which at the time of completing the form and years after I had no idea on, I have not discussed him with any doctor and it does not specifically say anything in my notes apart from a family history ( which is my mother as explained)

 

Any ideas of what they are looking for or are they actually going through notes to make a positive decision. They said they may cancel policy, pay in full or pay part, would I accept part given I have done nothing wrong and not witheld any info i knew about.

 

Your views will be appreciated, its dragging on now thought it would be done.

 

Thanks

 

 

Gavin

[unclebulgaria67]

I think they are just stringing you along and making excuses as to why they need more information.

 

In this situation, you need to send a written complaint to someone senior at the Insurance company and advise them that you are considering litigation against them, to resolve the claim which they are currently trying to avoid. Then see how they repond and speak to a Solicitor who deals with such cases.

 

https://claonlineadvice.justice.gov.uk/

[Gavin0259]

Hi,

 

Thanks for the prompt reply, I went and seen my docter yesterday who confirmed that he had a new request. He said that their is nothing in my notes to state my cholesterol was high and I have always been very low risk so its nonsense what FL are saying he said, infact he said over the dates they requested I did not attend the surgery much at all. Also in my notes nothing says anything about my brother or that I have ever discussed anything with any doctor about it as FL said to me. He said all its says is previous family history in my notes which would relate to your mum most likely other than that nothing.

 

I spoke to a solicitor who also advised that I should not call them again and talk to them on the phone, I should write to them. She said I should write a letter confirming that I am not happy with the situation and how long the claim is taking and want a decision made and points highlighted why it is taking so long and what reasons they have not paid me. That after paying premiums I would have this dealt with but this is now causing me extra stress with it ongoing and continuously going back for more information to docter when they say they have everything to make a decision.

 

As I have never wrote a letter of this type before I was hoping someone could give me some help who a some experience of this, in what I need to write and cover and who I would need to send this to in FL

 

Thanks

[unclebulgaria67]

1) Send to Chief Executive Office by reecorded delivery

2) Mark as formal complaint in bold and underlined.

3) In central heading of letter - Complaint regarding handling of claim under (name of policy and policy number)

4) It is extremely important that you start the letter by saying that you are totally dissatisfied with the handling of your claim, which has caused unnecessary distress.

5) Then get to the point of the complaint and what your experience has been. i.e you submitted a claim on x date, due to (give reasons) and since this date, the people dealing with the claim appear to have decided to find every possible opportunity to delay the claim. Don't go into a long history of all the correspondence and phone calls. They won't read it and they will look at their files anyway. Just tell them that the claims handlers appear to have misunderstood information from your GP and keep asking for information that has already been supplied. Tell them it is getting to the point, where Solicitors are being consulted about the possibility of starting litigation, which you think should not be necessary.

 

6) Ask them for their help in resolving the complaint and confirmation of what actions they will be taking to ensure that the claim is looked at properly in the swiftest manner possible.

 

 

The point is that the Insurers are undecided about whether you knew of a family history of this medical condition and should have disclosed it. I don't know how you can evidence that you did not know about it. The claims handlers are obviously looking at an opportunity to decline the claim on the balance of probability that you did know of the family medical history.

[Gavin0259]

Thank you for the pointers and will draft a letter together to send out. I have the feeling this will be dragged out and may well end up with the FOS.

 

They will I suppose have to make the decision on balance of probability, which with no evidence or me to prove in anyway seems alittle unfair. I disclosed heart condition on the forms and my mother and would have my brother if I was aware of this at the time of completing my form.

 

Thanks for your advice

[honeybee13]

Hello guys.

 

UB, is it the fos or the FSA who have a helpline that can advise you if you have a complaint and how to progress things please? I wondered if that could be helpful.

 

HB

[unclebulgaria67]

Hello guys.

 

UB, is it the fos or the FSA who have a helpline that can advise you if you have a complaint and how to progress things please? I wondered if that could be helpful.

 

HB

 

It would be the FOS. The FCA is the new name for the FSA, but they don't deal with complaints as such and they only have a helpline for general consumer advice.

 

In this situation, I would be reluctant to let the FOS to deal with the complaint, as it could take a couple of years to get a decision, due to the workload they have. Think I would see what legal funding options are available and take this to court. If the OP is reluctant to use the courts at this stage, perhaps if necessary let the FOS deal with it for say 6 months and if it is not getting anywhere, then reconsider the legal route.

[honeybee13]

It would be the FOS. The FCA is the new name for the FSA, but they don't deal with complaints as such and they only have a helpline for general consumer advice.

 

In this situation, I would be reluctant to let the FOS to deal with the complaint, as it could take a couple of years to get a decision, due to the workload they have. Think I would see what legal funding options are available and take this to court. If the OP is reluctant to use the courts at this stage, perhaps if necessary let the FOS deal with it for say 6 months and if it is not getting anywhere, then reconsider the legal route.

 

Thank you. You're right, it had slipped my mind about the FCA change.

 

I wasn't suggesting asking the fos to deal, I know it's long. I just thought there was a helpline that tells you if you have grounds for complaint.

 

HB

[Gavin0259]

If I have to go down the legal court route what kind of costs am I looking at. I know I have the options of no win no fee solicitors.

 

Do I have any chance of funding, me and my spouse both work so cannot get legal aid, are their any other options. What kind of costs could I be looking at down the legal route and should I get an successful outcome would FL have to pay court costs?

 

The couple of solicitors I rang that deal with such cases did say that I have a good case as I declared my mother and would not have been expected to know about my brother or anyone else. The policy would have still been given if I declared if I had known. They said they could not doing anything really until such a time FL write and turn the claim down with the grounds for the decision. Hopefully the letter I send will speed this up i'd rather have a answer one way or another to move forward with this.

 

Thanks

[honeybee13]

Hello again.

 

I'll see if one or two of the legal guys can have a look at this thread while it's in the insurance forum. It can be moved to legal later if need be.

 

HB

[Gavin0259]

Thanks I appreciate that.

[steampowered]

At the moment this is theoretical. We don't know if they will decline the claim or accept it, and if they refuse to pay out we do not know what reasons they will give. Until that happens it is very difficult to know where you stand. The problem is that they are taking so long to do it so you don't know where you stand.

 

I don't understand why it is taking them more than two months. The first thing I would do is call the assessor and ask what is going on and how long they will take. At the same time contact their Customer Relations Team in accordance with their complaints policy (by phone on 0945 600 3122 and follow up with a letter to Customer Relations, Friends Life, The Core, 40 St Thomas Street, Bristol, BS1 6JX). If they don't hurry up, then it will be 'letter before action' threatening court proceedings to push them along

 

Answering your questions, if this did end up in court it is impossible to tell what the legal costs would be because we don't know what reasons they would give for refusing a pay-out or how complicated it would get. If you were successful and claim was above 10k they would most likely have to pay your legal costs.

Edited April 13, 2013 by steampowered