Financial Ombudsman Service Decisions for ME/CFS cases

Yogi · Jan 28, 2015

Valentijn · Jan 29, 2015

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

8) In getting treatments covered, make sure the cause for those treatments is objectively supported by lab results, etc, and not just "for CFS".

ukxmrv · Jan 29, 2015

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

worldbackwards · Jan 29, 2015

Valentijn said:
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.

I don't think I'd expect a company called Wesleyan to take ME very seriously

taniaaust1 · Jan 29, 2015

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

Aviva arranged for Mrs R to attend an independent medical examination with Doctor A,
whom she had first seen in 2009, in June 2012. She said she was too ill to attend but
surveillance footage from the day of the appointment shows she was out of the house for
several hours shopping and with her children. Another appointment was arranged for August
2012.

At the August 2012 appointment Mrs R reported, in summary, that she remained
incapacitated by her condition. She described herself as being ‘40%’ and not well enough to
participate in either CBT or graduated exercise therapy. She said that she could walk
unassisted inside her house but outside used a wheelchair to conserve her energy. She was
wheeled in and out of the examination by her husband. Doctor A concluded that given the
severity of her illness and the level of her recovery to date it was unlikely that she would
recover sufficiently to allow her to resume full time employment.

However, Aviva subsequently asked Doctor A to comment on surveillance that had been
taken over a period of seven days in April, June and August 2012. The evidence showed
Mrs R shopping, walking outside, and attending the gym. Doctor A said that the level of
functional ability displayed within the surveillance period was not consistent with her
presentation at the assessment.

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.

Q. How far (in metres) are you able to walk on a level surface without stopping? Please
describe the factors that prevent you from walking further than the distance stated
above?

A. I do not know in metres. I walk with dog some days for about 15 mins. I go food
shopping in supermarket about 3 times a month. If I do this I would not take dog out and

vice versa.

Q. What household or D.I.Y. tasks are you able to do?

A. Hoovering, mop floor, dusting, washing up, cooking, painting small areas i.e. not ceilings
or walls. Note: It is the repetition and quantity of exhausting tasks that I cannot do on a
regular basis. Therefore I could not hoover and mop floor, go shopping, take dog for
walk and gardening all in one day.

The surveillance of Mrs D was carried out over a single period lasting four days in June
2011. Consequently it only shows the activities carried out by Mrs D during that period.
However, the video evidence shows Mrs D working in her garden on three afternoons during
periods of five to seven hours. Mrs D is shown performing tasks in a standing position and
walking normally. She is pictured pushing a wheel barrow containing what appears to be a
heavy garden ornament. She is also pictured picking up and carrying a large container. On
one day, Mrs D left her home by car early in the afternoon and returned seven hours later.
Whilst she was out she made various visits during which she was walking normally and did
not appear to be fatigued.

I didnt expect to see tribunal cases looking so reasonable.

ukxmrv · Jan 29, 2015

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.

taniaaust1 · Jan 29, 2015

ukxmrv said:
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.

That's shocking to hear.

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.

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.

Valentijn · Jan 29, 2015

ukxmrv said:
It depends if the surveillance report as accurate and truthful?

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.

Financial Ombudsman Service Decisions for ME/CFS cases

Yogi

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Valentijn

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ukxmrv

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worldbackwards

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taniaaust1

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ukxmrv

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taniaaust1

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Valentijn

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