Critical illness insurance

[Sbag]

Has anyone had any success with critical illness insurance claims? ME is excluded in my policy but I took it out many years ago along with life insurance to cover a mortgage.
As it was excluded so many years ago I was wondering if that was because it was then commonly thought of as a mental illness. Do insurance companies have to give reasons for an exclusion? If it is still excluded because of this classification I was wondering if there was any way of getting it changed. There is the clause of disability and proving you wont get better but I know this is extremely difficult and from what I have read nearly everyone gets put under surveillance - is that the case from anyone who has been through a claim?

 

[charles shepherd]

You don't say if you are in the UK

If you are I have attached some general information and advice from The MEA on critical illness insurance problems:

Many insurance companies have been very reluctant to accept claims from people with ME/CFS in relation to critical illness policies

Problems often stem from the fact that critical illness policies contain a list of all the medical conditions they will cover, often with detailed inclusion and exclusion clauses attached, and ME/CFS tends not to appear in these lists as a condition that is INCLUDED

In some cases ME/CFS is actually EXCLUDED - see reference to ME/CFS under encephalitis in the Zurich policy document on page 18:
https://www.zurich.co.uk/internet/zurichintermediary/Documents/113293.pdf

So the way to make a claim might be under a section covering total and permanent disability

However, the small print defining PERMANENT and TOTAL disability can again make this very difficult for people with ME/CFS when the insurer disputes that ME/CFS is a permanent illness, or that it can cause major disability

To help cover this type of situation, we have an MEA information leaflet that summarises and references all the key published research data on prognosis and permanency in ME/CFS:
http://www.meassociation.org.uk/shop/management-leaflets/pensions-prognosis-and-permanency/

Two cases where people with ME/CFS were refused critical illness cover that are worth looking at if you are in this position:

From the MEA website:
http://www.meassociation.org.uk/201...y-on-income-protection-insurance-21-may-2011/

And a Financial Ombudsman decision:
http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=35737

However, there are now cases where people with ME/CFS have persevered with a claim - or involved a solicitor who specialises in this type of claim and succeeded

Information from Brian Barr - a solicitor who deals with ME/CFS and Fibromyalgia claims:
http://www.brianbarr.co.uk/category/critical-illness-insurance-claim/

We also work with a very good solicitor - James Millar Craig - at Royds Solicitors in London on insurance and legal cases. Contact details Royds are on the back page of ME Essential magazine

Details posted on MEA Facebook on January 2nd 2016 from a member who had won a critical illness case are below. The full discussion can be accessed using the search facility on MEA Facebook page.

SOMETIMES IT CAN BE SO WORTH PURSUING THESE CLAIMS AND THE LUMP SUM I'VE RECEIVED – £152,000 – DOES NOT AFFECT MY ESA!

Anonymous please:

I'm not sure if you will remember but I once asked the question regarding whether it was possible to claim against a life/critical illness policy I had that also covered me for total and permanent disability.

At the time, it was of the general opinion that I would be unsuccessful with a classic as ME/CFS is not a critical illness and is not considered to cause total and permanent disability.

However, I did decide to pursue a claim with Zurich. My original policy was with Allied Dunbar and was a whole-of-life policy taken out in 1998. The claim was submitted in February /March 2015.

After obtaining extensive medical reports as well as psychological one's, I finally received a decision at the beginning of October 2015.
I was told by the senior underwriter at Zurich that I had met the qualifying criteria and I was awarded the full amount of the sum assured: £152,000

I informed the DWP of this award and because it is a lump sum, does not affect my rights to receive Employment and Support Allowance as this is based on my National Insurance contributions.

I thought this information may be useful to your organisation as it may be of assistance to other sufferers.




Dr Charles Shepherd
Hon Medical Adviser, MEA

 

[Old Bones]

Has anyone had any success with critical illness insurance claims? ME is excluded in my policy . . . Do insurance companies have to give reasons for an exclusion? If it is still excluded because of this classification I was wondering if there was any way of getting it changed. There is the clause of disability and proving you wont get better but I know this is extremely difficult and from what I have read nearly everyone gets put under surveillance - is that the case from anyone who has been through a claim?

I have no experience with critical illness insurance. However, approximately 10 - 15 years ago I was denied Extended Health Care coverage under my husband's group employment policy after being honest on the application form. The Human Resources rep said I was the first person ever denied coverage. She "went up to bat" for me, but was unsuccessful. No explanation was ever provided -- yet another way in which ME patients are discriminated against. With no effective treatments, my claims would have been no larger than the norm, I expect.

 

[Sbag]

Yes I am in the UK. Thank you so much for your hugely detailed reply Charles. That has really helped to bring everything together. I had heard of one of the solicitors but not the other. My cover is with Zurich so I will go through all of the info you referenced and then see if I can proceed. Luckily I have a consultant and when I mentioned to him he is happy to support and write letters. Will go through everything later today - thanks x

 

[Sbag]

Having looked at my policy in a bit more detail I am actually covered for not being able to do my specified job. However at the time I did have depression so a clause was put into the agreement that i couldn't claim for anything of a mental or functional nervous disorder. I have spoken to the insurance ombudsman and there are two arguments I can follow - one would be whether ME is a functional nervous disorder and the other that the clause was related to depression and the ME is not related to the depression and therefore should be separate from that. The ombudsman said that they look at each case individually and just because it says something isn't covered they would take into account the context of it.
A quick question to my GP and he said he would classify ME as functional nervous disorder so does anyone have any thoughts on this? It seems to be a vague term used when nothing specific can be diagnosed although it does encompass most of the ME symptoms. If the majority agree it is functional nervous then I won't bother with this argument but if there are experts that say it isn't then it will be worth me getting evidence to support this part of the defense as well.

 

[Valentijn]

A quick question to my GP and he said he would classify ME as functional nervous disorder so does anyone have any thoughts on this?

I don't think it matters what your GP classifies it as. It's officially classified as a neurological disorder, so that should be what counts. But it does mean that you probably need a new GP

 

[Hajnalka]

Yep, the WHO classifies ME as neurological illness (G93.3) since 1969.

Doesn't "functional" always imply something psychological?

Can't say anything helpful, sorry. Just, that you're not alone, my German health insurance wrote me last week, that ME is psychological and that I'm kicked out and won't have any insurance two months from now.

 

[Sbag]

Nervous normally implies psychiatric but looking up functional nervous gets really varying results with MS parkinsons dementia being listed as this on a couple of sites. Interestingly John Hopkins in the US class ME/CFS as a contagious disease!

 

[charles shepherd]

Having looked at my policy in a bit more detail I am actually covered for not being able to do my specified job. However at the time I did have depression so a clause was put into the agreement that i couldn't claim for anything of a mental or functional nervous disorder. I have spoken to the insurance ombudsman and there are two arguments I can follow - one would be whether ME is a functional nervous disorder and the other that the clause was related to depression and the ME is not related to the depression and therefore should be separate from that. The ombudsman said that they look at each case individually and just because it says something isn't covered they would take into account the context of it.
A quick question to my GP and he said he would classify ME as functional nervous disorder so does anyone have any thoughts on this? It seems to be a vague term used when nothing specific can be diagnosed although it does encompass most of the ME symptoms. If the majority agree it is functional nervous then I won't bother with this argument but if there are experts that say it isn't then it will be worth me getting evidence to support this part of the defense as well.

There are plenty of doctors, especially neurologists, who believe that ME/CFS is a functional neurological/nervous syndrome/disorder

On the basis that these patients have neurological symptoms but not what the neurologists would regard as neurological disease/pathology....

Reference:

http://www.functionalmovementdisord...ads/2013/08/Stone-Bare-Essentials-Functional-
Symptoms.pdf

From Dr Stone's review:

IS IT YOUR JOB AS A NEUROLOGIST TO DEAL WITH THIS PROBLEM?

If you find people with ‘‘neurological symptoms but no disease’’ tiresome and not really what you came in to the specialty for, then you are going to find large parts of your job tiresome and—worse—your attitude will filter through in a negative way to the patients regardless of the form of words you use to talk to them. On the other hand, if you
allow yourself to be interested by the complexity of the problem and can see the potential for benefit that you, as a neurologist, can make to some patients then you may discover that this is a worthwhile area

 

[Sbag]

After being turned down on the phone when I called them about this. I queried their reasons and asked them to write to me with a full explanation of why it was being refused and how they categorised a functional nervous disorder and what guidelines they followed when making the categorisation. In the meantime I've been doing some research so that I can go through the complaints process once I receive their letter.
All the information I have found indicates that they aren't allowed to class ME as a mental illness. The problem here will be whether the terminology "functional nervous" means mental or physical. There doesn't seem to be an official description of this term and in some cases it means anything to do with the nervous system. In the majority of cases it means mental health though and I did find current exclusions which are being used today by insurance companies to support this -

I have seen some cases where this is discussed in court but if anyone has any information on which are the best for using as precedents then please let me know.

 

[Sbag]

attaching the image here in case it didn't post in above

 

[Valentijn]

The problem here will be whether the terminology "functional nervous" means mental or physical. There doesn't seem to be an official description of this term and in some cases it means anything to do with the nervous system.

If there's ambiguity in the language, a judge would probably define the term in your favor, since they wrote the contract and it was their job to be clear.