Former triathlete 'faked chronic fatigue to claim millions in insurance'

[*GG*]

This is pretty unfortunate. He could very well still have CFS. I can suck it up for 5 hours to meet friends at a beer festival on some days. On the outside I look normal, but I'm struggling inside. But I wouldn't be able to do much the next day or wouldn't be able to repeat such an outing if I was having a "bad day."

Also, I don't personally drink anymore in an attempt to be and get healthy but alcohol never affected me or my CFS. Actually, I became immune to alcohol's intoxicating effects. I can't get drunk strangely. But I know I'm an exception.

I agree, but I do get drunk, fall asleep without my meds. The alcohol helps kill some of my pain, so that is not as demanding upon my body. And as long as I don't get really drunk, don't wake up the next day feeling much worse. I am bed for 10 to 12 hours!

I had a few drinks at home this fall/winter watching the NFL.

GG

 

[RogerBlack]

I don't believe it's as bad as in the UK -- I know quite a few Canadians who are receiving CPP benefits who are not 100 percent disabled 100 percent of the time -- the criteria for receiving CPP payments is that you can't sustain any kind of employment at any time. So you might be able to do stuff around the house or go to a pub and not get hauled in for cheating the system or lying.

Anyways, not about Canada, it's about some man in the UK being called a faker for going to the pub.

The above is about insurance, not about disability benefits.

In principle, the UK scheme for PIP (personal independance payment) requires that you be able to do a list of tasks:
As often as needed to maintain a normal life with minor adaptions, to an acceptable standard, safely, and within twice the time taken by a normal person.

If you can't do a thing as often as you'd want to on a day most days (to the above standard), you can't do it.

The list of tasks is such things varying from 'Can walk 200m with no problem', 'can stand and walk 20m', 'can attend to toilet needs', 'can navigate to unfamiliar places alone'.

In principle, this list is (with the addition of the reliability criteria) not unfavorable to those with CFS.

The practical assessment may differ.

I am currently able to - sometimes - do all of the things on the list. I cannot reliably or with the other caveats do them often enough that it does not affect my life.
I am at the moment in receipt of the highest rates of PIP both for mobility, and care.

 

[JohnCB]

Not a great article. I find it very strange -- this all or nothing position on disability in the UK. You have to be 100 percent disabled 100 percent of the time or you aren't disabled????

Is it?

The primary disability benefit in the UK is PIP (which recently replaced DLA). It clearly doesn't require total disability as PIP can be paid to people in work. The purpose is to compensate for extra expense incurred due to disability. It can also be paid to people out of work. Clearly you have to establish a level of disability to qualify.

There is also ESA. This is paid as income replacement for people who cannot work due to illness or disability. The qualifying rules are different and are about ability to work.

It is possible to claim one or the other independently. It is also possible to claim for both. I used to receive both ESA and DLA which has been replaced by PIP. PIP can be paid beyond retirement for those in receipt before retirement.

The newspaper article does not seem to apply to state benefits however, but to an insurance policy. The rules in question will be those applicable to the policy. The insurers can be quite fussy as some permanent health policies can pay as much as 75% of lost earnings, much more than you get on state benefits.

The court case is surely about the conflicting claims. The judge is there to decide on the truth of the matter. I'm not sure that we can decide simply on the basis of a short newspaper article.

PIP = Personal Disability Payment
DLA = Disability Living Allowance
ESA = Employment Support Allowance

 

[Undisclosed]

Yes, I understand the newspaper article is about an insurance case. I was just making a general comment mainly on the bias of the press (the title is a disgrace) and how disability is defined in the UK. There are so many in the UK -- ME or not who have lost all their benefits due changes in the government rules, are living in poverty etc because they are deemed not 'disabled' enough. There are some horror stories out there -- both from the insurance sector and government sector.

 

[heapsreal]

Who actually gets payed out huge amounts of money from insurance for cfs? Lucky if any organization recognizes it???

 

[Snow Leopard]

Drives to the pub. I'm CURED!!!!!!!!1111111111oneoneoneone

The guy might have been faking it, but there is is a complete lack of evidence presented to suggest that he was.

 

[Aurator]

Clearly there's a lot of leeway for an insurer to decide what someone who genuinely has ME/CFS should or shouldn't be capable of doing. Are we to assume there is no condition that this insurer would pay out for if it still allowed you to spend five hours in a pub occasionally?

What it would be interesting to know is Mr Miley's activity levels before he became ill and what they are now. I trained and raced (on a bike) 150-200 miles every week before I became ill. Now, I can still ride my bike, but only for a few miles, only at a modest speed, and only occasionally, and my body's reaction is nightmarishly different from the reaction it used to exhibit pre-illness.

If someone saw me riding my bike now they might conclude there was nothing whatsoever wrong with me. But that'd be because they're only looking at the "after" and not the "before", and they're not seeing what happens in the aftermath of the bike ride. What hurts most is the suggestion that my present activity levels are a matter of choice, when the loss of my former life is nothing less than a bereavement.

 

[Dechi]

@Aurator what you're saying is so true ! You've expressed very well something I've felt since the beginning.

What you're saying also applies to intellectual tasks. You might look at someone with ME, how they talk and seem composed, but how can you judge if you haven't seen them before, and if you don't get to see the impact that effort has on them after the fact ?

 

[anniekim]

Yes, I understand the newspaper article is about an insurance case. I was just making a general comment mainly on the bias of the press (the title is a disgrace) and how disability is defined in the UK. There are so many in the UK -- ME or not who have lost all their benefits due changes in the government rules, are living in poverty etc because they are deemed not 'disabled' enough. There are some horror stories out there -- both from the insurance sector and government sector.

I agree that Uk state disability benefits such as PIP (which replaced DLA) have narrowed the criteria compared to DLA and more people are not getting awards as the new criteria effectively mean they are not disabled enough. I am bedridden so fulfil criteria but if I was at the level of illness I was for the first few years of my illness, I would struggle to be awarded anything for PIP whereas under DLA at that time I did fulfil criteria for some level of award. It's very tough for many people.

 

[RogerBlack]

I agree that Uk state disability benefits such as PIP (which replaced DLA) have narrowed the criteria compared to DLA and more people are not getting awards as the new criteria effectively mean they are not disabled enough

I disagree that the new criteria compared to the old criteria for CFS, properly applied are more rigorous.
Yes, the policy intent was to reduce the cost of PIP WRT DLA 20%. (this has not happened), but how this applies will depend on your particular disease and set of symptoms and how they map to the new descriptors.

For example, with DLA in order to have the highest rate of the care component, you need to be able to reasonably need significant care during the night. This is defined as 'when the household goes to bed' - so it's not just after day. (whether or not you actually were able to get that care).

With PIP if:
You can't cook a simple meal without help from fresh ingredients, in under twice the normal time, safely, reliably and as often as a non-disabled person might, then you get some points.
If you're not showering or bathing, or need to take rests, or ration your energy and shower less than you might otherwise, again, points. (again, with above bolded part)
SImilarly for dressing and undressing - do you skimp on selection of clothes, or their cleanliness, or does it take you longer than twice, or ...
Do you communicate verbally easily, or might it take you twice as long to explain things, or you explain them wrong - again.
Similarly for written information - if you can't take in written information at the same speed as you would normally expect - potential points.
Engaging with people, and financial decision-making too.

The upper tribunal made this comment as part of this decision on the social descriptor of PIP, commenting on someone who could do a thing only sometimes.

2015 UKUT 215 AAC

It appears to me that, in relation to the question whether the claimant could engage with other people at least 50% of the days, as often as that activity was reasonably required and to an acceptable standard, there was abundant evidence which was accepted by the tribunal and which entitled the tribunal to conclude that he could not do so. Being able to put on an act on special occasions, even a few times a week when going to the drama group, after lengthy preparation does not fulfil the criteria of the descriptor and the tribunal has made more than adequate findings as to why in other respects he was in general not able to engage with other people to an acceptable standard. Being able to do so by way of an act in very limited circumstances is not as often as reasonably required even on those days when he can do so.

 

[anniekim]

Thanks @RogerBlack you actually have made a fair point about the care part of PIP if properly applied being more generous than DLA care component. I was referring to the mobility component being less generous now than DLA. Now to get high rate mobility you can only get it If you can't walk more than 20 metres reliably, repeatedly and safely. When I first applied late 90's for DLA there was no fixed distance and people could get high rate mobility up until distances of 200 metres or so. In recent years I think people were finding they were awarded high rate mobility for 50 metres, though a fixed distance was still not written down, decision maker's discretion. So many people have lost their high rate mobility award in the transfer to PIP I think they must have made savings for mobility part. Of course it's possible more are getting care awards than before. I haven't looked up the figures or know if they have been released?

Regarding the care component, although I am now severely affected and bedridden 24/7, they insisted I could cook a meal as there is a microwave at the end of my bed for my carer to place my meal in for me to warm up later. After almost getting to tribunal they finally gave me four points for saying I could cook a meal with fresh ingredients with assistance despite me clearly explaining and breaking down in great detail why I can not cook at all in my bed using the microwave at the end of my bed even with assistance and my doctor confirming I am bedridden 24/7. Utterly ridiculous. Ditto washing, even though I have bed baths!

It was utterly impossible for me to get points for written and communication despite the tribunal ruling you gave above and likewise with other severely affected patients I know. As I spoke very slowly to the person with my eyes closed who gave me a face to face assessment interviewing me in my bed at home she said I had no problems with communication and written communication. I explained in detail on the form I couldn't do this repeatedly but they wouldn't budge. Also interviewing me from my bed with me obviously weak and eyes closed you would think it was clear I could not communicate easily for more than 50% of the day. I finally just managed to scrape enough points for high rate care but this was after mandatory reconsideration and they only stopping me going to tribunal and finally awarding me high rate care as I made it clear (with medical evidence) I would have to have the tribunal at home. So in theory high rate care should be possible for severely affected M.E due to our many limitations but in practice they are making it very hard for many applicants. Yet you are right on paper the care component should be seen as easier to get as no longer is overnight care required to get high rate.

 

[Yogi]

More articles on this:

http://www.insurancebusinessmag.com...ential-2-4-million-insurance-fraud-63040.aspx

http://www.dailymail.co.uk/news/article-4320642/Financier-claims-2-4m-insurance-payout-fatigue.html

http://www.standard.co.uk/news/uk/f...4million-from-insurance-company-a3491306.html

The insurer is Friends Provident.

William Hamilton is the CMO of Friends Provident.

http://forums.phoenixrising.me/inde...-concerning-prof-hamilton.11070/#post-192264\

He was reported to the GMC.

www.meactionuk.org.uk/GMC-REDACTED-complaint.doc

Dr William Hamilton of NICE Guidelines judicial review fame did not disclose FP in his NICE GDG declaration of interests.

http://www.meactionuk.org.uk/Hamiltonwitnessstatement.pdf

'Insurance industry and psychiatrists fraudulent lobbying in CFS/ME NICE guidelines then accuses CFS/ME policyholder of fraud.'

That should be the real story for an investigative journalist.

 

[RogerBlack]

Thanks @RogerBlack you actually have made a fair point about the care part of PIP if properly applied being more generous than DLA care component. I was referring to the mobility component being less generous now than DLA. Now to get high rate mobility you can only get it If you can't walk more than 20 metres reliably, repeatedly and safely. When I first applied late 90's for DLA there was no fixed distance and people could get high rate mobility up until distances of 200 metres or so. In recent years I think people were finding they were awarded high rate mobility for 50 metres, though a fixed distance was still not written down, decision maker's discretion. So many people have lost their high rate mobility award in the transfer to PIP I think they must have made savings for mobility part. Of course it's possible more are getting care awards than before. I haven't looked up the figures or know if they have been released?

Most of the fuss about 20m was before the 2013 amendment to the regs which added 'reliably' and the other caveats to the above. These make it arguably similar.
https://pipinfo.net/issues/reliably

With DLA, there was no real explicit time period, and very, very slow walking could count.
With PIP, if it takes you more than twice the time period, you can't do it.

Also, this is not 'of a limited life' - it's not 'can you walk 20m once a day' - once.
It's 'can you walk 20m most of the time you would normally expect to, if you were not disabled'.

How this is applied in practice may differ.

I did not dispute with PIP that I could walk over 200m, once, in a special occasion, with possible cost to my health.

I argued that I could not "Can stand and then move more than 1 metre but no more than 20 metres, either aided or unaided.", because my ability was such that on most days I could not do this reliably, safely, ... as often as I would might normally hope to.

For example, I listed what I would normally do on a day when I was feeling very well, and related it to number of times I might '... 20 meters" .
For example - 'tidying up in the garden' 40*20m over the course of a couple of hours. Taking rubbish out - 10*20m, walking from the kitchen to the bathroom, rather than using the sink, walking outside to dry in the sun in the greenhouse.

And then compared to a typical day, and how limited I was, and what I was explicitly doing to avoid walking, because I could not cope.

This is (for normal people) entirely routine. If you can't do them most of the time because of your disease, even if you are now letting the garden rot, and rubish pile up, and not washing - your life is limited, this applies.

 

[Aurator]

It seems Mr Miley has been cleared of faking ME-induced disability.
I'm pleased for all of us that the judge has shown such an unusual level of understanding about the condition.

https://www.thesun.co.uk/news/4614886/banker-insurance-payout/