Group Income Protection Denied

[clarkenuttal]

I am starting this thread on behalf of my brother who desperately needs some help.

 

He should've been on Group Income Protection by September

however due to his bad health he never chased that up.

 

He was then invited to attend a functional capacity assessment on behalf of insurer in January which itself was around 4 months later than when he should’ve started on income protection.

 

He gave in his 200% in that assessment to a level that he ended up being with swollen legs and pain for next 2 weeks to follow.

 

His illness started around March last year when he was getting bullied at his work place which caused him work-related stress and depression.

 

The bullying continued and that lead him to a stage that he experienced paralysis symptoms in left side and lost strength in left side of body and he ended up being hospitalised.

 

Subsequent tests and check-ups, physiotherapy (neuro physio), neurology consultants after thorough diagnosis ruled out stroke (luckily) and diagnosis were work related stress that caused his functional hemiparesis (losing strength in left side of his body).

 

During this time, the management were still stressing his through different means while he had been off sick as a result his stress and depression got so out of control that it triggered Schizophrenia in him including hearing voices and hallucinations.

 

Things like not being around for the family and being unable to carry out day to day activities worsening his condition and since then he is in care of Mental Health team.

 

After a month,

he received a letter of rejection quoting my brother doesn’t fulfil definition of incapacity and his claim was getting rejected.

The basis of rejection was they believe there is no evidence of medical condition causing significant impairment in function and his reporting is inconsistent and unreliable (even though he disputes).

 

They cited clinician believed there were number of inconsistencies in my brother’s reporting and his ability of walking and standing during formal testing were inconsistent with his reported left side weakness (even though he pushed himself over pain barrier to carry out these activities).

 

They used around 1-2-day surveillance on him which was done approximately for around 1-2 weeks prior to his assessment and they quoted that surveillance showed him walk and stand unaided whilst grocery shopping and grip items and grocery shopping bags which doesn’t indicate functional loss.

Even though they agree there is evidence that he used walking stick and displayed uneven gait throughout surveillance footage.

 

He maintains that the bags referred to were very light.

He also says that he doesn’t do these as day to day activity

however on that particular day he was severely depressed as this shopping even though caused him physical pain

but he did that as it gave him distraction and mental reassurance that he is not a burden on others.

 

Now his mental health condition has further deteriorated due to further stress hence I am helping him with this and he has been given 90 days to appeal against this decision.

 

I wish to get advice on following:

 

1) What should be his first steps to challenge this?

 

2) Given that he is physically incapacitated (as per treating doctor, physio and consultant) what weight does assessment from functional assessors carry when they say he is not functionally incapacitated considering they are paid by the insurers?

 

3) Does just lifting some light grocery bags justify him not being incapacitated? Even though he says it is not one of his regular activities and he did that to fight his depression and it caused him significant pain and distress? Considering that even they mentioned that surveillance shows him using walking stick and maintaining uneven gait throughout the surveillance footage)

 

4) Even if we ignore him moving with support and with uneven gait for the sake of argument agree with insurers no functional loss argument does high degree of depression and Schizophrenia including voices and hallucination not constitute incapacity considering his job involves high physical activities and care?

 

5) Considering he was supposed to be on Income Protection in September was it a fair practice from the company to get his evaluation done in January (approximately 4 months later)?

 

6) Is assessing someone nearly 4 months after they should’ve been on Income Protection good indicator how their condition was 4 months ago?

 

7) What should happen for the time between when he was due to be on Income Protection and till they assessed him?

 

Any help is highly appreciated

[clarkenuttal]

Will subject access in this case will be relevant? I am thinking subject access might show their accessor's medical reasons and observations and my brother's own medical records that we can possibly challenge?

[honeybee13]

Hello there.

 

I was wondering if a SAR could be a good move, let's see what the forum guys think though.

 

Not many people here know about group income protection, unfortunately. However I know someone who had dealt with these in the past and will try to ask their views.

 

HB

Edited April 4, 2017 by honeybee13
Duplication.

[clarkenuttal]

Problem is the definition of Incapacity they quoted as "if you are unable to carry out material and substantial duties" I am baffled as he is in physically and mentally ill But their assessor thinks different to his treating doctors and consultants. They've also mentioned we agree he is stressed but stress itself is not a disease. But what they don't realise that he is so bad that he is not even physically and mentally around for his family so how on earth will he be able to perform material, substantial or even any duties specially knowing his condition is driven from work related stress in first place

[clarkenuttal]

I haven't had much advice so I am likely to proceed by making a SAR request tomorrow and hope to see their evidence for rejection

[sangie5952]

I haven't had much advice so I am likely to proceed by making a SAR request tomorrow and hope to see their evidence for rejection

 

I think your problem is that giving advice on these matters is exceptionally difficult if someone does not have full disclosure - we don't have the details available to help. We never could have. I don't deal with these sorts of insurances, but they are not dissimilar to our ill health retirement policies, and those are some of the most complex things to deal with because every case is totally different. The job someone does makes a difference. The possible option of other employment, perhaps even with a different employer makes a difference. The medical conditions are all different. There is no one size fits all. For example, I also walk with a stick over short distances, but need crutches for anything over about 100 ft. But that doesn't stop me from working. Someone else it might. And there are so many variables on that spectrum. But you have one very huge problem - they clearly don't believe him. Surveillance is not a standard procedure, and it's actually a very expensive one (i know someone who does this for a living so I know what it costs!). They are not spending that money unless they have serious doubts that he is telling the truth. And there is some measure of material in that which casts doubt on the veracity of his claims.

 

What you need to be clear about is that there is no reason why they must accept the view put forward by his medical practitioners. Their job is to report and act on what he tells them, not to doubt they are being told the truth. If his own medical practitioners get to that stage, it is likely to be a long way down the road - their first and foremost duty is to thoroughly investigate and treat medical complaints, not decided if they are real or not. But from what you have said, It appears that there is no actual physical evidence of any issue, so it comes down to a mental issue, which is much harder to prove and easier to fake. So the assessor, whose job is for the company, not your brother, is obviously going to test that. And what he has found, and what the surveillance has found, has led him to believe he is not being told the truth. They are also correct- stress isn't a medical condition. Without a clear medical condition, there is always going to be a question over his claim.

 

To be honest, I can't see a SAR having much impact. This is a specialised area - a lawyer who deals with personal injury and income protection claims is really what you need, but they don't come cheap. Not the best ones anyway. On the other hand, you may have no choice but to try an ambulance chaser. Just go in with eyes open and clarity about what you will pay them when and if you win. But something is better than nothing, and right now he has nothing. And, I suspect, no impetus to tackle this. It's a lawyer or a union, and you wouldn't be here if he were in a union.

[clarkenuttal]

I think your problem is that giving advice on these matters is exceptionally difficult if someone does not have full disclosure - we don't have the details available to help. We never could have. I don't deal with these sorts of insurances, but they are not dissimilar to our ill health retirement policies, and those are some of the most complex things to deal with because every case is totally different. The job someone does makes a difference. The possible option of other employment, perhaps even with a different employer makes a difference. The medical conditions are all different. There is no one size fits all. For example, I also walk with a stick over short distances, but need crutches for anything over about 100 ft. But that doesn't stop me from working. Someone else it might. And there are so many variables on that spectrum. But you have one very huge problem - they clearly don't believe him. Surveillance is not a standard procedure, and it's actually a very expensive one (i know someone who does this for a living so I know what it costs!). They are not spending that money unless they have serious doubts that he is telling the truth. And there is some measure of material in that which casts doubt on the veracity of his claims.

 

What you need to be clear about is that there is no reason why they must accept the view put forward by his medical practitioners. Their job is to report and act on what he tells them, not to doubt they are being told the truth. If his own medical practitioners get to that stage, it is likely to be a long way down the road - their first and foremost duty is to thoroughly investigate and treat medical complaints, not decided if they are real or not. But from what you have said, It appears that there is no actual physical evidence of any issue, so it comes down to a mental issue, which is much harder to prove and easier to fake. So the assessor, whose job is for the company, not your brother, is obviously going to test that. And what he has found, and what the surveillance has found, has led him to believe he is not being told the truth. They are also correct- stress isn't a medical condition. Without a clear medical condition, there is always going to be a question over his claim.

 

To be honest, I can't see a SAR having much impact. This is a specialised area - a lawyer who deals with personal injury and income protection claims is really what you need, but they don't come cheap. Not the best ones anyway. On the other hand, you may have no choice but to try an ambulance chaser. Just go in with eyes open and clarity about what you will pay them when and if you win. But something is better than nothing, and right now he has nothing. And, I suspect, no impetus to tackle this. It's a lawyer or a union, and you wouldn't be here if he were in a union.

 

Thanks Sangie your comment really helps as it gives another point of view. I am however not sure what you meant about there is no physical evidence of any issue? (he is been accessed by his doctors, physios and consultants and they all agree on his condition)

 

To answer First and foremost on his condition and job which was your biggest area of concern. His job involves physically handling and caring for people some of them at high risk. There is no doubts on his physical ability as I can assure he can only do small distances that too with his stick and cant walk distances at all with or without crutches/stick. This is backed up by treating doctor, physio and consultants and even insurers say that in throughout surveillance he was seen to be walking with a stick and with an uneven gait. Therefore I was considering the SAR route to check what evidence is the insureres considering to decide this claim and what exactly does their accessor's report says about my brother?

 

On his mental health side he has a long history of mental health issue since his probably his pre teenage days so its not something he started faking. This was quite bad at one stage however it receeded and merely bothered him later on. After this bullying and stress incident his condition has worsened and is currently back to its peak days including hallucinations and for this he is been under the care of Mental Health team for last 5-6 months uptil now and this includes various teams such as CBT (Cognitive Behaviour Therapy) and others something that seems to be clearly disregarded by his accessor.

 

What is bewildering me is that knowing his job involves high level of care and physical activities how can insurers physio deem him fit for work when he cant walk without stick and is suffering from hallucinations? Also if his condition is triggered by work related stress (even though stress not being a medical condition) how will he recover if he is put back in same environment that caused him this issue in the first place?

 

Other points I need to seek clarification is Considering he was supposed to be on Income Protection in September was it a fair practice from the company to get his evaluation done in January (approximately 4 months later) and how can assessing someone nearly 4 months after they should’ve been on Income Protection good indicator how their condition was 4 months ago? Finally what weight does company's insurers assessment carries over his own treating doctors, physios and consultants?

[Swoosh84]

I'm a broker and work with these sort of products. There will be no need for a SAR, if he speaks with his employer they will be able to arrange for all the medical notes to be sent onto his GP. The insurers will not send it anywhere other than the registered GP.

 

You have every right to appeal and from experience they are successful. But you MUST provide additional information along with the appeal such as GP notes and other evidence.

 

J

[clarkenuttal]

I'm a broker and work with these sort of products. There will be no need for a SAR, if he speaks with his employer they will be able to arrange for all the medical notes to be sent onto his GP. The insurers will not send it anywhere other than the registered GP.

 

You have every right to appeal and from experience they are successful. But you MUST provide additional information along with the appeal such as GP notes and other evidence.

 

J

For now I am not even sure if insurers even considered his mental health side of illness therefore I wanted to see at their medical notes and video surveillance as even insureres maintain he used walking still with uneven gait all along.

How will I be able to receive from GP? Will they still send everything to GP if I requested a SAR. I want to see all the medical notes and evidence they have considered including their notes from their accessor which they have based their decision on so it can be appropriately challenged? I am also thinking of saving some time by doing this.

Do you believe that there is any element of breach as insurers were suppose to payout from September and it was not until January this year they decided to access him? If it is a breach then in your experience can we force them for a payout for such breaches?

[sangie5952]

Don't take this the wrong way, but being the devil's advocate, and as I said above, the doctors have found, from what you say, no actual evidence of anything. You say he hears voices and hallucinates? Prove it. You can't. And neither can any medical professional. They have to take his word for it because there is no empirical evidence of what he says. He walks with a stick and his gait is uneven. Impossible to fake? No. And they have found no physical reason for this or the weakness and paralysis - both of which are easy to fake too. There's no evidence he's faking it per se, but there's no evidence he isn't either. And the doctor for the insurers had clearly said he doesn't believe that what he says is true. The insurers have the money. So if they continue to be advised that the claim is false, they won't pay.

 

If I were to be in the position of making this claim, there would be clear evidence of a replaced hip, a severely arthritic hip, arthritis in the spine and a deformed ankle. There are x rays and MRI s to back up what my specialists are saying. But in his case there is nothing they can point to to say "that's what the problem is".

 

If you are going to help him here, you need to be more objective. Your relationship blinds you to that. It actually IS possible that he is faking it. That is your starting point - what do you need to prove he isn't? Stop thinking like a brother, and think like a rep. And if you can't do that, find someone who can. There's no shame in not being able to do it - but if you start from a position of being partisan, you aren't helping. Think about lawyers. They don't care whether you are guilty or not. They don't want to know whether you are or not. The defence is the defence - it's not about guilt. That's about objectivity. So you need to be his brother or be his representative - you are taking on an impossibly difficult task trying to be both.

[clarkenuttal]

I agree you been devil's advocate but in that case it would be between their Physio and my brother's treating Physio, doctor and Consultant etc. But thinking in a least optimistic way I am thinking down the route of SAR to understand what have they based their decision on. To understand all medical history and evidence they considered to make this decision and their own observations. That way it won't be any feelings but only medical evidence vs medical evidence?

Once I got that I will get him a solicitor or someone that can help may be from his own union. I also wonder the appropriateness of accessing him too late and if that could be a ground for challenge?

[sangie5952]

I agree you been devil's advocate but in that case it would be between their Physio and my brother's treating Physio, doctor and Consultant etc. But thinking in a least optimistic way I am thinking down the route of SAR to understand what have they based their decision on. To understand all medical history and evidence they considered to make this decision and their own observations. That way it won't be any feelings but only medical evidence vs medical evidence?

Once I got that I will get him a solicitor or someone that can help may be from his own union. I also wonder the appropriateness of accessing him too late and if that could be a ground for challenge?

 

He is in a union? Get to the union straight away. You don't get a solicitor or the union can't represent him. He should have got on to the union right away.

 

I honestly don't know the rest. Some policies actually have waiting period in them anyway - someone I know who retired on one of these policies had to be off for six months before it would pay out. We don't know the terms of the policy here.