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Group Income Protection - Claim Declined


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After they decline you can appeal, they have 8 weeks to respond with a final decision and if not satisfied you ave the option of taking to the financial ombudsman.

 

My main concern is that my employers will not allow me to take it to the FOS and instead terminate my employment if the insurers reject the appeal.

 

These insurers and employers do have a very friendly relationship and can use this process to get the best result for them, which defeats the objective if you fall ill for a long period.

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Well, personally I'd be trying to find out as much as possible about how their appeals work, but it's up to you. I had my own problems with another insurer's income protection claim years ago and I think I won by understanding their appeals process.

 

 

Do you have additional medical evidence to submit?

 

 

HB

Illegitimi non carborundum

 

 

 

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Sangie595, Sorry I just noticed your response.

 

The information they have provided states that they feel it is other factors not illness or injury that prevents me from doing the essential duties of my job, and that they do not consider me to be a incapacitated member.

 

Thanks

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Honeybee,

 

Yes I am arranging additional medical evidence as we speak. In terms of their appeals process there isn't any other information from them or my employer.

 

Thanks

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Sangie595, Sorry I just noticed your response.

 

The information they have provided states that they feel it is other factors not illness or injury that prevents me from doing the essential duties of my job, and that they do not consider me to be a incapacitated member.

 

Thanks

 

 

Can you give us the exact wording of this please? Wording is all important.

 

 

HB

Illegitimi non carborundum

 

 

 

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Here you go:

 

'we consider that it is other factors rather than illness or injury that is continues to prevent the performance of the essential duties of his occupation.'

 

'we will immediately end payment of benefit if the insured member ceases to be disabled'

 

Thanks

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Ah. And that is what we have been asking you for all along.

So they aren't deferring it again - it's an outright refusal because they say you are not ill?

 

I suspected as much, but was thrown by the references to linked periods and deferred payments. If they are claiming you are not ill, then you will need a lot more than a note from the GP!

 

Do you have a specialist or mental health team referral? Anything else more than just the GP. Because, as I said previously, I am afraid that anxiety / stress are very easy to fake.

 

I'm not having a go at you - but stress is the new "bad back". Impossible to prove or disprove, and GPs tend to be less than rigorous in their diagnosis. Having actually told people how to successfully fake stress, I know it's neither difficult nor complicated.

 

I'm going to have to ask. I'm sure that you know what they are talking about. What, exactly, did you tell the rehab advisers? What did you tell them about work? Because that is a big problem.

 

If you are perceived to have an issue with your employer, and/ or to be faking your illness, then there is no reasonable way in which you can exist any support from the employer in this matter.

 

They won't tell the employer the full circumstances, but they'll tell them enough to at least give the employer a very good guess about what L&G know - and this is exactly the sort of thing that they aren't likely to back you up over.

 

I understand. I know how it happens. You get talking and yippy don't stop to think what you are saying. But what did you say?

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'we consider that it is other factors rather than illness or injury that is continues to prevent the performance of the essential duties of his occupation.'

 

 

 

 

Where I have seen similar wording used

- personality clash

- staying off when incompetent to do the job/ low performer - sometimes when the skills needed have changed over time, so no "blame" but just how things are

- staying off to look after other people in the family who need a carer, and claiming it as illness when special leave has run out

- series of illnesses due to being generally run down, but not amounting to a disaibility

 

 

If any of these apply, we may be able to advise on the best way forward from your current position, wether you wish to stay or leave employment.

 

 

But it is unlikely, without a lot of contradictory and time consuming medical testing, that you are going to get continued payment. I would think hard about wether you have the stomach for the fight, when there is slim chance of victory.

Never assume anyone on the internet is who they say they are. Only rely on advice from insured professionals you have paid for!

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Ps. Please would you go back to my post 14? I asked you a lot of questions and you haven't answered any of them. If you need to, send Honeybee the answers and she'll send them to me.

 

But, and I want to be clear on this in my usual entirely undiplomatic way... there is an issue between you and your employer.

 

Your insurers have picked up on it.

There is no point in telling us anything less than the full truth, because if you don't our advice will be wrong.

 

There is nothing much that you could say that will shock me

. There are loads of lousy employers out there.

There are loads of lousy colleagues out there.

There are even lousy employees.

 

I'm a trade union official, but I don't think anyone has a corner on being right or sensible! I just know, and have thought this for quite some time now, that there is something else going on.

 

I need to know what it is.

The best advice isn't always, or even often, the advice you want.

You are drip feeding information to get the advice you want.

 

Believe me, it might not be the advice you need. P

Please tell us what is going on.

Via site admin if you can't post it here.

 

Then I can figure out a sanitised version of the advice to put here for you. You are obviously in trouble, and we're trying to help.

But that isn't always the help you think you need.

 

Another Ps - I cross posted that last post with Emmzzi.

But I agree with her totally.

She gives great advice, and she's very experienced I'm told.

Which always shows in her advice.

 

You've now got two people telling you there's a problem.

Let us help you fix it.

Even if the fix isn't what you hope for.

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Hi Sangie, thanks I do appreciate it,

 

Honeybee has said that DX100UK has forwarded my PM onto you, let me know if you didn't get it was sent yesterday and if you need any further clarification.

 

In short I gave an honest representation of the situation at work which they were aware of during my initial absence.

 

I did discuss lack of support/adjustments for my symptoms when I returned to work and also the issues I PM'd you but at no point did I state anything that confirmed that these were the reason I was absent from work or they were preventing me from returning to work.

 

my illness has progressively gotten worse over what is now a 20 month period. But the insurers have taken statements that I made from different calls to come up with their conclusion. (I have described all this in the PM sent to you)

 

My GP is supportive and I have a consultant who is also will to provide a report that I am not fit to work and confirm that my illness is related to a previous illness. Please let me know if you have got the PM and message me back with any detailed points you want to know about and I will respond to you straight away.

 

Again thanks for your advice I do appreciate it.

 

Sorry I should have said none of the points that Emmzi kindly mentioned apply in my scenario, everything I related to them was around conversations with my employer around lack of support and how my illness affected me before I relapsed. Anything else I have stated I have sent to you in the PM which hopefully you have and if not Honeybee will now forward to you.

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My GP is supportive and I have a consultant who is also will to provide a report that I am not fit to work and confirm that my illness is related to a previous illness. Please let me know if you have got the PM and message me back with any detailed points you want to know about and I will respond to you straight away.

 

In case it helps, could we confirm please whether both claims were for anxiety and depression or something else? What does the specialist do?

 

 

HB

Edited by honeybee13
Repetition

Illegitimi non carborundum

 

 

 

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Yes they were although I was diagnosed during my first absence but any health questionnaire by councillors and the insured showed anxiety and depression. The consultant is a cancer specialist and has seen my illness before.

 

Sorry that should read I wasn’t diagnosed during my first period of absence

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So claim one was for cancer?

 

And claim two is for anxiety and depression?

Never assume anyone on the internet is who they say they are. Only rely on advice from insured professionals you have paid for!

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No -

 

Claim 1) was for stress related illness - then returned to work for a month and a half and relapsed (although I was scoring high for anxiety and depression but this information wasn't shared with me.)

 

Claim 2) is a continuation of the original symptoms - and I was diagnosed with anxiety and depression a couple of months after I relapsed

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And the consultant is a cancer specialist because...?

 

A psychologist would seem more appropriate.

Never assume anyone on the internet is who they say they are. Only rely on advice from insured professionals you have paid for!

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He has experience of my condition and feels it is related to my previous illness and has medical evidence from previous studies which shows this.

 

I have been referred to a psychologist and waiting for for some counselling sessions I almost also currently on medication.

 

I don't mind seeing a private psychiatrist if it helps.

 

All I really want out of this is to get better and return to work what I don't want is to return to work and have another relapse and go through what I went through previously.

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Ok. I can't advise without a full picture, and your drip feeding information suggests you value privacy more than you want help.

 

I wish you the very best and hope the people you have PMd can offer better advice. I dont offer advice by PM for the reasons Sangie stated in an earlier post.

Never assume anyone on the internet is who they say they are. Only rely on advice from insured professionals you have paid for!

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No problem thank you Emmzi I appreciate it. I'm sorry I can't provide a fuller picture but there isn't much more to what I have already mentioned. I'm hoping that once Sangie gets my PM he can maybe fill in the gaps.

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I haven't had a PM from anyone.

But anyway, I'm not convinced I can really say much more.

A cancer consultant is not a specialist in mental health, and whilst I suspect everyone could go with a general statement that people with cancer would have times of depression or anxiety,

 

I don't think that means the same thing as all depression and anxiety is caused by cancer. It is clinically possible to have two disconnected causes, for two instances of the same general condition. That makes this a dispute on clinical expertise, not employment.

 

However, I may be misreading this, but it appears that you have said some things to the rehab specialist about your employer; and those things you have said appear to cast some negative opinion about how well they have acted towards you. Is that correct?

 

Because if that is the case, then whilst three insurers should not have disclosed the detail about what you said, they are certainly within their rights, whether or not they are correct in their assessment, to tell your employer that they believe the cause of the current complaint is to do with you position at work, not "real sickness". That seems to be the argument you are suggesting they are making.

 

Now that is an employment issue, and it's the reason why the employer isn't going to support any litigation for you. It'd be a rare instance an employer would anyway - precedent on that would be horrendous.

 

But the thing is that you may have made allegations about their lack of support or adjustments which result in a potential liability to them. Basically, if you are saying these things, it's entirely possible you might take legal action against them for those things.

 

They aren't going to take legal action on your behalf when that potentially is a conflict of interest for them as they might have to defend themselves against the very allegations that the insurer alleges you have made. And no court in the land will force them to.

 

I'll be honest. Unless you can come up with a good strategy here, I don't see that you will be able to just return to work. It appears that the relationship with the employer is, at best, not great. And nor is your health

 

. Why do you think any of that is going to change? In which case, and I'd possibly be expecting this as the next step, it is possible that the employer and the insurer might make an offer of a lump sum settlement for your resignation. I've seen that happen often. But it won't be a fortune if they do.

 

Alternatively, I think your only option is the Ombudsman. And you may not win. Or yippy may get nothing more than that settlement at the end of it anyway.

 

You may need to carefully consider whether the eyes of all this is also going to adversely impact on you.

 

If you think that a settlement might be better, you may want to think about what kind of sum you are looking for.

 

But that's all based on a very incomplete understanding of the whole situation.

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Hi Emmzzi,

 

Can I just ask, you mentioned that their is a very slim chance of getting a payout. Is this even if I take the matter to the FOS?

 

 

 

 

you'll be an eternity getting a response. not worth it.

Never assume anyone on the internet is who they say they are. Only rely on advice from insured professionals you have paid for!

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Hi Emmzzi,

 

Can I ask you (not doubting your experience and if you don't mind) what do you base that on and what background do you have? Its just that I have seen cases similar to mine upheld by the ombudsman.

 

Many Thanks

 

Hi Sangie,

 

Just read your response - all of what you have said is correct, how can we look at the settlement side of things?

 

I'm still keen to take it to the ombudsman if it means that my claim is reinstated and I have seen similar cases to mine upheld by them.

 

My health is bad at the moment but the more time I have to get the medical help I need before I return to work the less chance there is of a relapse and this time I want to ensure that I am supported on my return to work and have certain adjustments confirmed as I have been diagnosed with depression and anxiety which from my understanding is protected by law as a disability.

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Hi Emmzzi,

 

Can I ask you (not doubting your experience and if you don't mind) what do you base that on and what background do you have? Its just that I have seen cases similar to mine upheld by the ombudsman.

 

Many Thanks

 

 

 

 

Then by all means go for it. I have no idea what your actual case is, in order to have an opinion.

 

 

 

And you should ever trust that anyone on the internet is who they say they are. Let's assume I'm a professional clog dancer.

Never assume anyone on the internet is who they say they are. Only rely on advice from insured professionals you have paid for!

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Hi Sangie,

 

Just read your response - all of what you have said is correct, how can we look at the settlement side of things? I'm still keen to take it to the ombudsman if it means that my claim is reinstated and I have seen similar cases to mine upheld by them. My health is bad at the moment but the more time I have to get the medical help I need before I return to work the less chance there is of a relapse and this time I want to ensure that I am supported on my return to work and have certain adjustments confirmed as I have been diagnosed with depression and anxiety which from my understanding is protected by law as a disability.

 

I am running out of things I can say to you.

 

You don't, as far as I know, ask for a settlement. You make yourself annoying enough to get offered one! Or that's my experience. I usually do that by asking lots of awkward questions and threatening, or going, to the FO.

 

But my threats usually carry a lot more weight than yours might. That said, I've occasionally helped non union friends (i have a few!) and they've usually been offered a settlement. Eventually.

 

I always suggest caution on "cares you have read". I hear this all the time. The cases usually never say what people think they say. There's a human capacity to read what you want it to say.

 

And I keep saying this... It gets frustrating.... A disability in law can ONLY be determined by a tribunal. Nobody else can decide it. Not a doctor. Not a lawyer. Not ACAS. Not me. We can all guess, but that doesn't make it so, and in my experience doctors make the worst guesses, because they are doctors and know next to nothing about the law!

 

The support and adjustments that you want are not relevant, even if it's a disability. The support and adjustments the employer thinks are reasonable are what you get! And right now the employer is being told that you aren't ill, you are actually just not liking your employer!

 

That gives them a reasonable case to say that what you want is about something other than disability and they don't have to even consider it. Disability is not protected by law. There may be some grounds for some adjustments, but that's it. No protections.

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