PHI & The Financial Ombudsman

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HAPPYGIRL

Registered User
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Hi,

I had a PHI policy with my job - I then became ill with ME & later received a diagnosis of Chronic Lyme Disease. The insurance company would not pay me under my PHI policy as they say that I am fit for work - despite numerous test results & specialists confirming the above diagnoses. I appealed in every way possible with the Insurance co. & eventually lodged a complaint with the Financial Ombudsman (through my solicitor).

The case is being investigated at the moment - with a result due within the next 6 weeks. I have submitted all doctors' reports, test results etc with my complaint form. However, I am still having new tests done to see is there any other casue for the illness...so my question is - should I inform the Ombudsman's office that I am still undergoing an investigation? I'm wondering if it might strengthen my case?

There is quite a bit of money as stake (a few years payment), but also the principle - as my illness is real & the claim is valid.

Has anybody here ever had to make a claim similar to this before? Any advice/comments would be greatly appreciated.

Many Thanks!
 
I'm sorry about your illness firstly.

Your case is highly unusual.

I've a bit of experience in relation to PHI and claims thereon, and tbh I've found the leading insurer in the area to be fair.

Who is your insurer?

If anything relevant to your health has not been submitted it should be.

I hope it works out for you.
 
Many Thanks for you reply.

Can I say the name of my insurer on here or should it be in a pm?
 
I'm sure you can say it publicly. Friends First are the market leaders in this area btw.
 
RS2K said:
Friends First are the market leaders in this area btw.
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Really??!! That's who my policy is with. I have found them so unhelpful & they have dragged everything out - and basically done everything they can not to pay me.

It has been a nightmare for me - its hard enough being ill without this too! I have had lots of treatment & been to lots of doctors - trying to find the underlying cause of the illness & trying to deal with it & get well again - but the doc they sent me to said that I was basically going from one doc to the next trying to find someone to agree with me - even though all of the specialists diagnosed me with M.E. He also said, in so many words, that it was all in my head! I wish - it'd be easier to deal with then!!

Also their Chief Medical Officer in this area is a doctor who I saw for the insurance co for my credit card (payment protection), confirmed the diagnosis of ME & I have this in writing. The amounts involved are different - maybe this has affected his decision? I owed very little on my cc- whereas the amount on my PHI policy is 75% of my annual salary.

I rang the Ombudsman's office today & told them of the new tests/investigations & they said that this wouldnt have much bearing on my case as they deal with the case "as is" but if I get new test results before the investigation is complete, that I should send them in. Tests will probably be in January at this stage - and the investiagtion should be complete in mid Jan (16 weeks is the average investigation timeline).

I think M.E. is such a grey area as there is no specific diagnostic test for it so its, unfortunately, easy to dismiss it. However there are specific tests for Lyme Disease.

Thanks again for your reply.
 
I'm not medically qualified H.G. but I do know a few things.

PHI benefits and claims thereon are usually pretty much cut and dried cases. That's why yours is unusual.

They have only one C.M.O. countrywide.

Their business is paying claims (and making a few bob on the way on overall underwriting. They've done it for many years and are good at it imho). My experience is they don't deliberately welsh on paying claims. Someone somewhere is clearly stating that you shouldn't be paid as you are fit for work. I'm not saying who's saying it, or if he/she is right or wrong. I can't.

You've confused me on one thing "The amounts involved are different - maybe this has affected his decision? I owed very little on my cc- whereas the amount on my PHI policy is 75% of my annual salary." What does this mean?
 
Sorry if that last part want very clear, I'll try to explain better:

I saw their CMO for a different claim entirely (credit card payment protection) & at this time he said that he had no doubt that I had M.E. & was unfit for work, however , when he looks at my file for this claim (PHI), he said that I am fit for work. The amounts of money involved in the two claims/policy would be very different as the cc one was a small amount, whereas the PHI one is 75% of yearly salary.

A doc whom I saw at their request said that he doesnt believe that I have M.E. - and this is the main bulk of their evidence.

Because there is no specific test for M.E., it is easy for claims to be denied unfortunately.

Thanks again for your reply.
 
HAPPYGIRL said:
Sorry if that last part want very clear, I'll try to explain better:

I saw their CMO for a different claim entirely (credit card payment protection) & at this time he said that he had no doubt that I had M.E. & was unfit for work, however , when he looks at my file for this claim (PHI), he said that I am fit for work. The amounts of money involved in the two claims/policy would be very different as the cc one was a small amount, whereas the PHI one is 75% of yearly salary.

A doc whom I saw at their request said that he doesnt believe that I have M.E. - and this is the main bulk of their evidence.

Because there is no specific test for M.E., it is easy for claims to be denied unfortunately.

Thanks again for your reply.
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Understood now. As I said I'm not a medical person. I'm not sure the maounts should make any difference tbh. If you are unwell and qualify for benefit then you should be paid.

If you think you can't work then fight your corner I'd advise.

Best of luck.
 
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