Appeal a declined total permanent disability claim
Why are total permanent disability claims rejected?
Thankfully, every year, thousands of total permanent disability claims are successfully paid out by insurers. But still, lots of claims are still declined.
In our experience, there are three main reasons why your total permanent disability claim may be refused:
1. The insurer doesn’t believe your condition will impact you this way permanently
In order for your total permanent disability or loss of independence claim to be paid, the disability must have a permanent impact on you.
Particularly in the early days of your condition, if there isn’t a clear indication of what the future will look like for you, your insurance company may be reluctant to pay out. In our experience, this can often be the case for conditions such as Fibromyalgia, Chronic Pain Syndrome and Chronic Fatigue Syndrome (CFS/ME) amongst others.
Our team has experience in formulating complaints and appeals in this complex and niche area of claims management and are happy to advocate on your behalf.
2. Your insurance company says that you didn’t tell them something about your health or lifestyle when you took your critical illness insurance policy out
This is known as non-disclosure which is a type of misrepresentation. You can read more about this in our guide to non-disclosure and misrepresentation.
Appeal Avenues team have vast experience of assessing and forming complaints and appeals in this complex area of claims management.
3. Your insurer says that your condition doesn’t meet their claims criteria
Insurance companies have different criteria around what they define as total permanent disability. This generally falls into two categories, the first being your ability to carry out certain activities of daily living and the second being whether or not you can continue in your own or any occupation.
Our team has a lot of experience in this aspect of claims management. We find that the disputes normally involve the insurer not agreeing that the policyholder is incapable of carrying out their occupation, or performing the activities defined in the policy terms.
What do I do if my total permanent disability claim is declined?
Let Appeal Avenue handle your complaint or appeal for you
Appeal Avenue specialise in supporting people who’ve had total permanent disability and loss of independence claims rejected.
On our first call, we will talk to you about your situation, this will include questions about your health and how your disability impacts you. If relevant, we will also ask you questions about your occupation. Our team will make time to listen to your side of the story.
If you’re happy for us to act on your behalf, we would then review your policy terms, your medical records and how your insurer reached their decision. If we believe the decision may be incorrect, we’ll write a complaint or appeal for you.
Appeal Avenue can advocate on your behalf through every aspect of the declined insurance appeals process, giving you the time and space to concentrate on your health and wellbeing.
Using our vast knowledge and experience of this very niche and complex area, we can write every letter, speak with your insurer and medical professionals, ensuring that your appeal is presented in the best way possible. Rest assured your complaint is in safe hands with Appeal Avenue.
We offer a no win, no fee advocacy service where we can handle the appeal on your behalf. You’ll only pay if we’re successful.
Make your own complaint or appeal following our guide below
If you would prefer to submit your own total permanent disability appeal, follow the process below. We are here, if you find this process overwhelming, or if you need any support.
1. What are the insurer’s reasons for declining your claim?
Ask the insurer to explain their reason for declining your claim in writing. Work through this in a logical way- if you don’t agree with what they have said, make notes as you go through the letter, so you can come back to it later.
If the reason for their decline is because they say you didn’t tell them something about your health or lifestyle when you took the policy out (often referred to as non-disclosure or misrepresentation) visit our non-disclosure and misrepresentation page for more guidance..
2. Gather evidence for your appeal.
Depending on the reason for your insurer’s decision, it might be a good idea to gather evidence that contradicts what they are saying. This might involve looking at your medical records or obtaining confirmation and clarification from your doctors.
3. Write your complaint.
– We would always suggest making your complaint in writing, this gives you the opportunity and time to plan, consider and reflect on what you want to say.
– Try to be as logical as possible and refer to the points that the insurer has made in their decline letter.
– Include a timeline of what has happened and put the date you send the letter of complaint at the top.
– Try to remain calm and professional- you don’t want to detract from the complaint.
– Reference the evidence you have gathered that contradicts what the insurer has said.
– Always focus on what your policy terms and conditions say.
– If you are in severe financial difficulty- make sure you state this in your complaint letter and request that the insurer prioritises your complaint if possible.
– Make it clear what you are looking for as an outcome to your complaint.
4. Wait
Your insurer should send you an acknowledgement within a couple of weeks to let you know they have received your complaint and are investigating it- if you don’t receive this acknowledgement, you should contact your insurance company to make sure they received your letter.
The insurer has 8 weeks to investigate your complaint.
5. Response
Your insurer will respond to your complaint in writing.
If they ‘uphold’ your complaint (which means that they agree there has been a mistake) they will tell you what they plan to do to put things right.
If they don’t uphold your complaint (they still disagree), they will tell you why. They will also tell you what you can do next if you wish to pursue the complaint further.
6. Escalate your complaint to the Financial Ombudsman Service
If the insurer did not uphold your complaint and you are still unhappy with their decision, the next step is to take it to the Financial Ombudsman Service.
The Financial Ombudsman Service is there to independently review your complaint. They will consider the facts of what has happened and will listen to yours and the insurers opinions. They will then give an unbiased decision on what should happen next.
There are two ‘tiers’ within the Financial Ombudsman Service. Your complaint will firstly be reviewed by an ‘Investigator’ who will consider the facts of the case and issue their viewpoint.
If you, or the insurer, disagrees with the Investigators decision, you can ask for it to be reviewed by an Ombudsman. The Ombudsman will independently review the facts of the case and will issue their ruling. The Ombudsman’s decision is binding on the insurer.
If you disagree with the Ombudsman’s decision, the next step would be to seek legal advice from a qualified solicitor.
Ready to get started?
Start a new claim or get help with your appeal for declined critical illness insurance today.