What to do if you are having problems with a permanent health insurance claim

When dealing with an insurance claim, whether it is a group or individual policy, a number of problems may arise. Here, our team of specialist solicitors give you the guidance you need so you can understand the best way to proceed.

Alternatively, if you need further information from our team, contact us directly to see how you can claim for denied health insurance.

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Your claim has been denied

This could be at the start of the appeal process, for either a group or individual PHI policy. Either way, combating their medical evidence in conjunction with your own medical advisers early on is key to success.

Often the employer is either not particularly supportive or fairly inattentive regarding the necessary paperwork for an appeal. They may no longer be paying you because of your long-term absence, the main issue is to first obtain a copy of the insurer’s Letter of Refusal and then request copies of any documents it refers to.

The documents may contain reference to material from other doctors, or from the insurer’s Chief Medical Officers (CMOs), who in reality are often self-employed doctors such as retired GPs. Insurers may be reluctant to disclose this information and if they are not prepared to do so a formal request should be made under the Data Protection Act. The letter may also be inaccurate about your medical condition.

Your claim is being reviewed

If you are receiving payments under a group PHI scheme your claim will be regularly reviewed. Often insurers will try and do this on an annual or even more regular basis.

The Financial Ombudsman Service have established that a reasonable period for a review is not less than every 12 months. Insurers sometimes try and put a claim under almost continuous review i.e. setting up a review which lasts over six months and then almost immediately starting a new one. These reviews are particularly stressful. As well as forms to complete, a review may well consist of a visit from someone appointed by the insurers.

Insurers may also request an appointment with a medical expert nominated by them. In the event that this happens, it is sensible to take advice before such an appointment, request a copy of their CV, take someone with you to any appointment, and avoid any request for a home visit. It is possible that the expert they select will be an Occupational Health Physician (or even a Psychiatrist) rather than one relevant to your particular medical condition. The GMC Good Practice Guidelines (2013), state that the doctor should have expertise in the condition and should not leave out any relevant material.

Other matters to consider carefully in a review are any Activity Questionnaire sent to you by insurers. These are forms with limited space so always attach a more detailed schedule. Great care needs to be taken in completing the form. Insurers also actively use surveillance and monitor social media.

Your claim has been terminated

This will obviously come as a great shock and, in the event your claim is terminated, urgent advice needs to be taken.

Initially, the Letter of Termination needs to be carefully considered. For example, the first letter will normally not be marked as a “Final Decision” letter, leaving the opportunity to appeal against it before a Final Decision Letter is issued.

Once a letter is issued marked Final Decision Letter” there is only a six month time limit in which to make a complaint to the Financial Ombudsman Service so care needs to be taken to put in the best possible appeal within this period.

The key issue (which the Ombudsman will also consider) is your own medical evidence; specifically any consultant’s evidence. Other important documents are your precise job specification and your analysis of any reports or surveillance obtained by insurers.

Again, if reports are not disclosed by the insurer, a request should be made under the Data Protection Act. If surveillance has been carried out, request in writing both the DVD and also the written reports. Urgent advice should be taken on any Letter of Termination.

What happens if you are made a lump sum offer by the insurers?

For ongoing, long-term claims an insurer may offer you a lump sum.

Careful consideration and urgent legal advice needs to be taken on any lump sum offer. Refusal of a lump sum offer does not necessarily lead to a quiet life in the future. The fact is that the file will have come to the top of the pile and refusal of a lump sum offer may well lead to the insurer targeting the claim and indeed seeking to terminate it at a later date.

However, before any lump sum offer is refused it is worth considering both the amount offered and whether insurers would be prepared to increase it.

The best prospect of obtaining an increased offer is when there is up to date medical evidence; without rejecting the offer out of hand a request can be made to insurers for a more reasonable sum, to which you should always copy in your employers.

You need to remember that any lump sum will be less than the total value of a policy up to the date of termination (often the age of 65) for three reasons:

  • your health might improve enough for you to be able to take up some kind of employment
  • you are receiving the money up front and can invest it how you wish
  • you may regrettably die before the termination date in the policy.

A lump sum offer will normally be made direct to the employer or their broker. You should request in writing a copy of the offer letter and ask about the time limit on the offer.

What do you do if you want to accept a lump sum?

If you want to accept a lump sum offer, you should give it urgent attention because there will be a time limit on the offer. However, without prior tax clearance, it will be subject to tax and therefore may not be reasonable or acceptable to cover your needs.

The employer who is the insured under the group scheme should apply on your behalf to HMRC for the appropriate tax clearance under Section 406 (b) ITEPA 2003. This provides that a prior application must be made by the employer to their tax office requesting tax clearance with up to date medical evidence. This can normally be in the form of a GP letter and a consultant’s letter. HMRC will also request a copy of the terms and conditions of your employment and the offer letter from the insurer.

One difficulty with obtaining tax clearance is that we are seeing an increasing number of cases where employers – particularly large ones – say they are too busy to get involved with making an application for tax clearance. A solicitor should therefore offer you assistance in the application for tax clearance and in liaising with your employers.

Contact us to find out how our specialist team can help with your denied health insurance claim.