Making a complain to an insurance company

mirrorwall14

Can anyone tell me what you need to put in a letter if you are making a formal complaint to an insurance company? It's in relation to income protection and annual rejection of claim despite multiple medical evidence sources (including clinics and consultants) to support it. The only doctors who has ever said she is fit to work are the two the insurance company hired. It's been six years of battles and stress getting the claim reinstated

skippy2

Make the complaint official, they normally have a procedure you have to follow before you can go to the Ombudsman and ask them for a "final answer" on it, i think they have 8 weeks to respond then take it up with the Financial Services Ombudsman.
You can then provide all your reports etc to the Ombudsman.
Ask them specific questions.
Provide medical evidence why they are refusing your claim.
Why are they basically calling your consultants liars if they say you are unable to work.
Mention how the six years stress is affecting you health.


You "cannot" return to work if your doctor certifies you are unable to do so whatever their doctors say is irrelevant.............Your employer cannot employ you in those circumstances.
Their doctors are not independent.......... i am sure they do regular work for this insurance company
Get your consultant to ask explicitly in their letter if they are saying she/he is lying when he/she states you are unable to work and to provide medical evidence to backup their claim...... only she/he has your best interest at heart.
Are their doctors qualified in the field they are making judgements on? ie Neurologist, Cardiac, etc
Have you been assessed by an occupational therapist and declared unfit for work?

I presume the company you are dealing are a specific "Irish" company

mirrorwall14

The person has been deemed unfit to work by occupational health and been medically retired by them (deemed unfit to ever work again in their field). They have both private and public consultant doc/clinic reports all stating they are unfit to work. The two doctors they have are not specialised in the field yet the company has still suspended the claim.

We sent a formal letter of complaint last week. Will update the thread when I know more for potential other readers looking for info on a similar situation

Sue Pa Key Pa

You should get a response fairly quickly, acknowledging your complaint and outlining the timeframe for a formal decision. Your complaint will either be resolved or 'signed off' to allow you advance to the next stage with the Ombudsman. If you got (and you should have), a Terms of Business booklet from your insurers, the procedure should be in there. Either that, or it will be on their website

notharrypotter

mirrorwall14 wrote: »

The person has been deemed unfit to work by occupational health and been medically retired by them (deemed unfit to ever work again in their field).

I am curious if someone is deemed unfit to continue in a current role but could work in a different field would this be grounds for refusal of a claim?

mirrorwall14

notharrypotter wrote: »

I am curious if someone is deemed unfit to continue in a current role but could work in a different field would this be grounds for refusal of a claim?

I've no idea. By their role I mean their actual profession in this case. There has been no mention by the insurance company of other rroles

NUTLEY BOY

notharrypotter wrote: »

I am curious if someone is deemed unfit to continue in a current role but could work in a different field would this be grounds for refusal of a claim?

That would probably depend on the wording of the specific insurance contract.

The contract might define benefit as being payable if the claimant is unable to perform a specified job or any job at all.

NUTLEY BOY

mirrorwall14 wrote: »

Can anyone tell me what you need to put in a letter if you are making a formal complaint to an insurance company? It's in relation to income protection and annual rejection of claim despite multiple medical evidence sources (including clinics and consultants) to support it. The only doctors who has ever said she is fit to work are the two the insurance company hired. It's been six years of battles and stress getting the claim reinstated

A few observations ;

1. I think that there might be a six year time limit back beyond which the Financial Services Ombudsman's Bureau (FSOB) may not be able to go. That might be for certain financial products sold more than 6 years ago and may not apply here. However, you can ask them for clarification now even though you are not ready to present a formal complaint.

2. FSOB link https://financialombudsman.ie/

3. The repetitive stonewalling facing OP's lady is not rare for certain types of conditions like M.E. or C.F.S. and the like.

4. The claimant carries the burden of proof that she is entitled to benefit under the policy.

5. The standard of proof would be the civil standard of the balance of probabilities. This means that something is at least 51% more likely than not.

6. The insurers are obviously trying the approach that no matter how much evidence the claimant presents they - the insurers - have medical opinion that says otherwise and that that is the end of it.

A sub-variant on this tactic is to keep declining liability in the hope that the claimant will go away.

This is not a contest of building up so many medical reports on either side of a dispute the final judgment falling in favour of whoever has the larger number ! The persuasive quality of authoritative reports may be more important. For example, a report from one consultant neurologist on a patient may carry greater persuasive power and authority than three reports from less qualified doctors.

That said, the insurers cannot also just ignore all of the facts of the case as distinct from finding one point on which to justify their position and sticking to that whilst blissfully ignoring everything else.

7. BTW the medical consultants that insurers may engage to assess claimants are, technically speaking, independent medical advisers. In reality, some of them could be considered as "hired guns" because they may have a biased predisposition against certain medical conditions and so it suits insurers to engage them.

8. Does the policy have an arbitration clause or another clause that provides specifically for resolution of a dispute like this ? If so, that should be considered. Indeed, if there is an arbitration clause the dispute might have to be dealt with that way.

9. The insurers are obviously seeing all of the claimant's medical reports. Has the claimant seen any of the insurance company's reports ? They may not be automatically available for the asking but I would request sight of them "with a view to mind of trying to understand the incomprehensible attitude of the insurers to the claim".

10. Without prying in to clinical details, this is obviously a matter of significant substance where the claimant has been retired on medical grounds and the problem has become clinically chronic. That makes the insurer's attitude seem all the more irrational. I suggest retaining the services of a solicitor as I feel instinctively that you are being pushed around by the insurers.

11. A possibility that arises here is the strategic notion of engaging a medical consultant who does specialise in the claimant's particular clinical condition. That could then be juxtaposed to considerable effect against the insurer's expert opinions.

Good luck with this one and, to borrow a phrase, don't let the ********* grind you down ..........