‘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

The Sunday Telegraph - Money & Business - - Front page - Money Tele­graph

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.”

Newspapers in English

Newspapers from UK

© PressReader. All rights reserved.