Case Study

Mr J’s (names shortened/changed for anonymity) had a joint Life and Critical Illness policy with his wife through his employer. The policy had a ‘children’s benefit’ which means that if a dependant is diagnosed with a critical illness, it will pay a percentage of the covered amount (normally up to £25,000). Mr J decided to pay for the enhanced cover which covered more than the standard conditions.

Mr J’s wife was pregnant with their third child and a routine scan picked up an anomaly which suggested an increased chance of Cystic Fibrosis (CF). Unfortunately, shortly after their son’s birth a diagnosis of CF was confirmed by blood tests.

He logged a claim with his insurance company who declined the claim. They advised that the policy did not pay for pre-existing conditions or symptoms of pre-existing conditions. They reasoned that as his child only entered the policy when they were born, and the prenatal scans showed symptoms of CF, this was in fact a pre-existing condition.

Mr J was was unhappy at the decision and opted to contact us. At Resolute Claims, in order to successfully appeal declined Critical Illness claims, we need to make evidence-based decisions. We requested all policy documents along with the terms and conditions of the policy. We also thoroughly examined the best available research and up to date information on prenatal testing and Cystic Fibrosis.

We noticed Mr J’s enhanced children’s benefit specifically covered Cystic Fibrosis. We identified that most CF cases are identified prenatally with regular scanning (which is commonplace in the UK). Our team also identified that standard blood tests are conducted in the UK in the days following birth to identify CF.

Using our expertise, we managed to persuade the insurance company that their cover was not fit for purpose.

The insurance company revised its procedures for all Cystic Fibrosis claims and paid Mr J £25,000 plus interest at 8%. Mr and Ms J were able to take time off work to ensure their son had the care he needed without having to worry about their monthly bills.

If you feel that your children’s Critical Illness claim has been unfairly rejected, you can speak with one of our experts, in confidence, today 0333 050 8792.