Case Study

Alan had been suffering from chronic fatigue for years which had gotten progressively worse. He had been to see a few consultants and was diagnosed with Chronic Fatigue Syndrome (CFS) and Fibromyalgia. Around 5 years after his diagnosis he felt he was unable to work any more.

"For every good day I had there were four bad days, I just couldn’t commit to working any more" Alan said. He looked at his Critical Illness policy and noticed he had Total Permanent Disability cover (TPD) so decided to make a claim.

TPD cover is normally included in Critical Illness policies and pays out if you are unable to work or do listed ‘living/daily tasks.’ This needs to be permanent and unlikely to change for the rest of the person’s life. Alan felt like he had met the policy definition and filled out the claim form online. Unfortunately, after assessing the claim for 16 months the insurance company rejected his claim.

The insurance provider pointed out the TPD cover would only pay out if he were unable to do ‘any’ job again rather than his ‘own occupation.’ They said that although they agreed he could not do his current role again there was no evidence to suggest that he could not do any job again.

They also said that Alan was still going through treatment and, until the treatment stops, there was no guarantee that the condition or symptoms were “permanent”.

“They just make you feel like you’re lying and that you’re not really ill. The assumption was that most people can live and work with it so why can’t you. The whole thing has a massive impact on my mental health, which in turn made my condition worse”.

Alan was frustrated as he had been a builder for 25 years and was unsure he had the skills and knowledge to do any other role. He contacted us to ask for help in appealing the rejected insurance decision.

CFS and Fibromyalgia are complex medical conditions and the symptoms can vary significantly from person to person. It’s often associated with severe pain and can impact work/lifestyle in the same way as other conditions such as cancer and MS. Most of these types of claims are finely balanced and often when claims come to us, it’s after several years since diagnosis and when the insurance company have finally rejected the Total Permanent Disability claim.

Often, we see insurance companies asking for unrealistic or never ending medical information. Thankfully we are often successful in getting insurance companies to pay claims. Our evidence-based approach gives you the best possible chance of success.

We managed to successfully appeal Alan’s claim using up to date medical research along with regulatory and legal guidance to prove that the insurance provider must pay out and, after going to the Financial Ombudsman, managed to secure a pay-out of £98,620 plus interest of £8,922.

Claiming on a Total Permanent Illness policy can be complex and time consuming, the last thing you want when you are unwell. We can use our expertise in this area to help people who need extra support to get the pay-out they deserve. If you’ve had a Total Permanent Disability claim declined speak to us today about appealing the decision 0333 050 8792.