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We’ve all seen them in the news stories about ME/CFS: the guy in a suit at the office, yawning; the beautiful woman sitting at her desk with her immaculate make-up and elegantly coiffed hair, hand to her head and looking slightly pained.
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Financial Ombudsman Service Decisions for ME/CFS cases

Discussion in 'Finances, Work, and Disability' started by Yogi, Jan 28, 2015.

  1. Yogi

    Yogi Senior Member

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    Only the bottom three were upheld. 3/11 upheld. 8/11 rejected.

    These are from 2012 onwards. They get removed from the FOS website after a while.

    If anyone has time/energy it would be good to upload these to PR website and could help others down the line.


    Phoenix Life Assurance Limited
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=40225

    HSBC Life UK
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=35737

    Legal & General Assurance Society Limited
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=59585

    St Andrew’s Insurance Plc
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=63795

    Aviva Life & Pensions UK Limited
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=48377

    Unum
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=42753

    Phoenix Life Limited
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=30806

    Catlin Insurance Company (UK) Ltd
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=27082

    The Royal London Mutual Insurance Society Ltd
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=34730

    Aviva Life & Pensions UK Limited
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=25278

    Wesleyan Assurance Society
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=31900

    t Liverpool Victoria Friendly Society Limited
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=38646
     
    Last edited: Jan 28, 2015
    ukxmrv, Valentijn and Esther12 like this.
  2. Valentijn

    Valentijn Senior Member

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    It seems like the biggest problems were uncooperative doctors and policies which exclude ME/CFS either explicitly or by having it not included as one of the diseases which are covered. Granted, it's not nice to see ME/CFS described as not having a physical cause, but if it was pre-existing and specifically excluded by the insurer, of course the claim will fail.

    I'm not sure what to think about Miss "I need a wheelchair to leave the house, but was caught on video running errands with the children for several hours." PEM can certainly allow that activity in milder cases, but she obviously wasn't consistently as severely affected as she had indicated.

    The claim against Catlin is more problematic. NICE was used as a basis to avoid paying for anti-viral medication. There's no indication of whether or not she had tested positive for any reactivation of viruses, which should be a pretty important factor.

    The case against Royal London succeeded because the specialist and GP said the condition was very likely to be permanent and was highly disabling regarding the work performed by the ME patient. An optimistic physical therapist nearly screwed thing up by cluelessly blathering on about the good prospects of recovery for a cooperative patient, but later submitted a correction of earlier statements, describing them as having been very optimistic.

    The 2nd Aviva claim succeeded because the patient described her symptoms and limitations quite well to the insurance company's doctor, even before the ME/CFS diagnosis which came after the policy was terminated.

    The claim against Wesleyan succeeded because the supportive specialist who had seen the patient for years had a lot more credibility than someone hired by the insurance company who saw him once.

    The Liverpool one involves an ME/CFS patient, but the insurer's arguments had nothing to do with the illness. More of a procedural matter, since they tried to deny coverage based on pre-existing pain not disclosed when applying for the insurance. But that medical information was accidentally released to them, and they weren't allowed to consider it. Since they didn't make any other arguments, it's hard to tell if there would have been any quibbling regarding the CFS diagnosis itself.

    So basically:
    1) If you have mild ME/CFS, it's probably a waste of money to take out a policy which explicitly excludes disability caused by ME/CFS.
    2) Get a policy which is based on disability, rather than being restricted to cover only certain illnesses.
    3) Make sure your doctor knows and records all of your symptoms on a regular basis. This might mean making some otherwise pointless appointments to simply list new or worsening normal ME symptoms.
    4) Make sure your doctor is supportive, and not a psychobabbler. Get a copy of your medical records if you aren't sure.
    5) Give detailed accounts of symptoms and limitations to medical assessors when required, and keep a (audio?) record of the interviews.
    6) Don't overstate your disability, and notify the insurance company and your doctor of any changes.
    7) Protest the misinformation disseminated by NICE and get it removed. Easier said than done :meh:
    8) In getting treatments covered, make sure the cause for those treatments is objectively supported by lab results, etc, and not just "for CFS".
     
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  3. ukxmrv

    ukxmrv Senior Member

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    I wonder how many of these insurance companies have Medical Advisors in common? I'm reminded of Dr Hamilton who was an advisor to the Liverpool Victoria Friendly and others and was subject to a complaint by Professor Hooper.

    "Dr Hamilton was a member of the National Institute for Health and Clinical Excellence (NICE) Guideline Development Group (GDG) that in August 2007 produced NICE’s Clinical Guideline 53 on CFS/ME (chronic fatigue syndrome/myalgic encephalomyelitis). He was invited to be a member of the GDG specifically because of his published views on CFS/ME (http://www.nrr.nhs.uk/2006AnnualReports/Section2A-2E.asp?O=582"

    "...Dr Hamilton’s published views suggest he believes it to be a functional disorder."

    In his Witness Statement (appendix 1), Dr Hamilton informed the High Court:

    “I am chief medical officer of Exeter Friendly Society”.

    “ I am also chief medical officer of Liverpool Victoria Friendly Society”.

    “For the sake of completeness, I note further that I attained a third insurance appointment (with Friends Provident). That seems to have been omitted from the declaration of interest by way of oversight on my part”.

    At paragraph 13 of his Witness Statement, Dr Hamilton stated that he obtains half his annual salary from working for these insurance companies. Dr Hamilton’s wife also works as a medical officer for an insurance company (BMJ 2010:340:c1799)."

    http://www.meactionuk.org.uk/GMC-REDACTED-complaint.doc
     
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  4. worldbackwards

    worldbackwards A unique snowflake

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    I don't think I'd expect a company called Wesleyan to take ME very seriously ;)
     
  5. taniaaust1

    taniaaust1 Senior Member

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    The bottom 4 tribunal cases won their cases..
    ..........

    One of the lost cases did sound frauduent, if I was a judge I would of declined that one too.
    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=34730


    A few hour shopping trip, I assume without the wheelchair she said she uses, on the same day she said she couldnt attend the court.. really doesnt look good.
    ...............................


    http://www.ombudsman-decisions.org.uk/viewPDF.aspx?FileID=59585

    I would of knocked but this other one too. They filmed her for 4 days straight and she had four very busy days straight for someone who said they can only walk a dog for 15mins. They insurance company wasnt even saying she could work full time, the case was a part time work dispute.

    I didnt expect to see tribunal cases looking so reasonable.
     
    Last edited: Jan 29, 2015
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  6. ukxmrv

    ukxmrv Senior Member

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    It depends if the surveillance report as accurate and truthful? I had surveillance taken of me and the report was incorrect. In the actual surveillance footage they cut out any parts which showed me as stumbling etc.

    Mrs R may have been traumatised by her appointment with the Mr A and not want to go back. Was he someone that she trusted or was he an obvious tool of the insurance company? I still have flashbacks from one that I was forced to see and the unpleasant and painful examination.

    The surveillance as done over 7 days in 3 months. How was she after these days (i.e. did she try the gym and then spend a week in bed). Did her doctor tell her to go to the gym? I went to a Gym to see a massage therapist and she took me into the gym and showed me some stretching exercises. It was a disaster to me but if included in my own surveillance video would have been damning.

    The company that was hired to do surveillance also tried untruthful ruses to tempt me out of the house. They didn't work on me but others may have fallen for them.

    I know that all sounds unlikely but having been under surveillance myself I'd like to hear the other side of the story before I come to any judgement.
     
  7. taniaaust1

    taniaaust1 Senior Member

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    That's shocking to hear.

    nods yeah to the gym part and its why I didnt highlight that as some do try to go to Gym to get better only to suffer later so I dont think much could be said about that, it doesnt even say what she was doing there. Its just the fact she said she was too sick to go to court, on same day she's out shopping with her children for hours I find doesnt make things with her sound right.

    It sounds as if she had a very good doctor supporting her being disabled until he was shown the footage.
    ..........

    I believe Im been put under surveillance twice now, one time for a week or near week and the last time quite recently since Ive moved into this new home for over a week (maybe 10 days).

    The first time was about 4-5 years ago..there was a car parked across my road with something weird on its internal mirror. When I crossed road to have a look (as I'd got suspicious about that car which obviously had nothing to do with my neighbour who lived there). I saw it was a camera attached to that mirror facing directly towards my home and yard. This happened back when I kept appealing to get onto a disability pension and they kept rejecting my claim (8-9 months, 3 appeals before I won).

    It was quite concerning back then as I certainly did at times have better days in which I was worried they'd see me having a very good day and film that.

    The latest incident... only about a month or less ago. Probably this time to do my fight with disability services and my taking them to court over ME/CFS discrimination against me. Im not too concerned, they could film me a year and really struggle to get anything on camera, my front yard is horrifically shocking as I cant do my yard (to film my yard would just prove that Im in a bad way here and I'd certainly point that out if I got filmed just walking to a car outside).

    I cant leave my home alone except with a support person.

    the disability service has resorted in playing mind games with me on the phone saying things like "I saw you walking around the shops all the time with a friend" obviouslly instead trying to get a strange reaction out of me to try to use against me.

    It arent going to work thou as I know they are lying as they certainly do not see me doing that all the time. I doubt if they would of even got me once up on my feet for a very very short time on an not often, occassion my friend did take me out to grab an item.. I nearly always use wheelchair and I'd be in and out of that shop very fast before I could collapse, so there is no way they could film me walking all about the shop and "shopping". I do not even stand at checkouts.

    I wish I got those nasty mind games on tape to play to the court when I share the way they have treated me.
     
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  8. Valentijn

    Valentijn Senior Member

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    The reports include the accounts from both parties - so if she did have any of those explanations for her actions, she didn't mention them. Her only excuse was that she was housebound the following day.
     

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