‘I didn’t know I had MS but my insurer still refused to pay out’
One reader thought he had protected his family but L&G trawled through his GP’S files for a pretext to say no. By Laura Miller
Insurers promise to look after you and your family if you get sick but, in reality, can be working hard behind the scenes to refuse payouts when you need them most. Evidence seen by shows that some insurance firms scour your medical records for signs of conditions to which you were oblivious, in order to decline your claim. Even backache or temporary blurred vision, often dismissed by individuals and their doctors as inconsequential, can be used as a basis to accuse customers of “nondisclosure” – essentially lying about their health – and void their policy.
Jan Trainor of BTW Solicitors, who acts on behalf of customers whose claims have been declined, said: “Insurers’ quest to find nondisclosure makes upsetting reading.”
Insurers are expected to review claims before paying out but internal notes released under customers’ right to see the personal data organisations hold on them suggests your guilt can be viewed as a foregone conclusion.
David Sinclair, 35, an engineer from Aberdeen, had a critical illness claim refused by Legal & General on the grounds that he had failed to disclose health issues.
Yet two separate claims reviewers at L&G found that he had correctly filled in its application form to the best of his knowledge at the time. One reviewer wrote: “The ‘have you ever’ questions ask about a specific illness that, arguably, at the time of application [Mr Sinclair] didn’t have. Nor had he sought medical advice.”
The other reviewer agreed: “Customer attended GP a couple of months after application and 33 days after PSD [policy signed declaration]. There are questions on the app for these types of symptoms but only if they have consulted [a doctor] do they need to tell us. The medical questions ask about anything you might see a doctor for in the next four weeks – this is outside the timescale for this, too.”
L&G then demanded all Mr Sinclair’s doctors’ notes from the past year. Ultimately, it refused to pay out, saying Mr Sinclair had not sought advice about symptoms that he had dismissed. He turned out to have multiple sclerosis, a disease covered by his policy.
Mr Sinclair said: “L&G’S opinion is that I should have known I was going to get MS. I didn’t even know what MS stood for when I was diagnosed. L&G implied that I lied on my application, that I should have known something was wrong.” Specialists say MS can be very difficult to detect, even for professionals. Frank Sudlow, who chairs Multiple Sclerosis National Therapy Centres, a charity, said: “Most GPS will only have seen one or two cases, so won’t spot the signs.”
Everyday aches and pains, balance problems, fatigue or forgetfulness are all signs that can be easily dismissed. Rosie Jones, who chairs charity MS Research, said: “This can account for the ‘having MS for a long time without knowing it’ scenario.”
BTW Solicitors, which is pursuing L&G on behalf of Mr Sinclair, said it was dealing with many similar cases.
Sufferers who have a critical illness claim refused often end up fighting the insurer, their illness and financial problems simultaneously. Mr Sinclair said: “I’m still working but it’s concerning if things go downhill.”
Critical illness cover pays a lump sum if an insured person dies or is diagnosed with an illness covered by the policy. With two young children and a fiancée whom he is due to marry this year, Mr Sinclair bought the L&G policy in March 2017 as a precaution to pay the mortgage if he was unable to work. He said: “It was for peace of mind. But I am a young man, so I had no expectations that I would need to claim.”
Under the Consumer Insurance Act 2012 you must “take reasonable care not to make a misrepresentation” when you apply for insurance. The Association of British Insurers’ code of conduct for paying claims states: “The severe remedy of voiding a policy from the outset should be confined to the most serious cases of misrepresentation.”
The last time Mr Sinclair had seen his GP was a year before he applied for critical illness cover. He had received a clean bill of health.
He said: “I answered all L&G’S questions on the application with my financial adviser, and there were lots.” The form asked if he was likely to consult a doctor in the next four
weeks. With no plans to do so, he answered no.
Weeks later, Mr Sinclair went to his GP with back pain. “I thought I needed physio as I work at a desk. He sent me to a specialist. One wasn’t available so I was referred for an MRI scan. Then the rollercoaster started.”
It wasn’t until almost three months after his application to L&G that he was diagnosed with MS.
A spokesman for the insurer said the answers in Mr Sinclair’s application were “inconsistent with the medical information received from his doctor while assessing the claim”, but it provided no evidence of this. The spokesman said if L&G had been aware of “the relevant parts of his medical history” it would not have offered cover.
Alan Lakey, a financial adviser who specialises in insurance, said if someone visited a GP or specialist without notifying their insurer while their application for a policy was going through, a declined claim would be reasonable.
“But if they did not and had no earlier symptoms, it would be unreasonable to decline it. I would anticipate the ombudsman finding in their favour”, Mr Lakey said. “Information at application must be truthful, and the applicant must advise of any changes between then and the actual start date. But once the policy starts, there is no obligation to advise the insurer.”