Appeal a declined terminal illness claim
Why are terminal illness insurance claims rejected?
Thankfully, every year, thousands of terminal illness claims are successfully paid out by insurers, but unfortunately, lots of claims are declined.
Insurers refuse to pay out on terminal illness claims for many reasons. In our experience, the top three reasons insurers do not pay terminal illness claims are:
1. They do not agree that your life expectancy is less than the 12 months stated within your policy terms
One of the most common reasons for declining a terminal illness claim is that the insurers claim assessor and Chief Medical Officer (CMO) do not believe your life expectancy is less than the 12 months needed to pay a life insurance terminal illness claim.
As you can appreciate, it can be so difficult to state a person’s life expectancy with absolute certainty. As a person’s life expectancy can be difficult to predict, we find that the policy holders’ own doctor and the insurance companies’ medical officer often disagree. Our team have vast experience of appealing and overturning refused terminal illness claims for this reason. We use our experience and training to argue whose medical opinion should be used to determine the claim outcome.
2. You submitted a claim towards the end of a policy that excludes terminal illness claims within the last 12-18 months
Some, but not all, life insurance policies have a clause that means a terminal illness claim can not be made within the last 12-18 months of the policy term.
If your terminal illness insurance claim is refused because of this clause, it is definitely worth speaking to us. More times than not, insurance companies make the right decisions, but sometimes they don’t. Our team have experience of appealing and successfully overturning these decisions.
3. The insurer says you didn’t tell them something about your health or lifestyle when you took your life insurance policy out
This is referred to as non-disclosure which is a type of misrepresentation; you can find out more about this on our non-disclosure and misrepresentation page
Again, this is an area that our team at Appeal Avenue have much experience of appealing and successfully overturning, so it’s certainly worth speaking to us if your insurance claim has been refused for this reason.
What do I do if my terminal illness claim is declined?
Let Appeal Avenue handle your complaint or appeal for you
Appeal Avenue, specialise in supporting people who’ve had terminal illness claims rejected.
We find that these types of appeal are the most distressing and difficult for the people making the terminal illness claim and their loved ones. Our team understands how upsetting these appeals can be and although it can seem like a clinical and heartless process, we will ensure that our conversations with you will always be sensitive and supportive.
On our first call, we will talk to you about your situation, this will include questions about your diagnosis, prognosis and health. Our team are trained to ask these questions in a sensitive and empathetic way and will take time to listen to your side of the story. If you’re happy for us to act on your behalf, we would then look at your policy terms, your medical records, and how your insurer reached their decision. If we believe the decision may be incorrect, we’ll form a complaint or appeal for you.
Appeal Avenue can advocate on your behalf through every aspect of the declined insurance claim appeals process, meaning that you don’t need to waste precious time away from the things and people that matter.
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 complaint or appeal is presented in the best way possible. Rest assured your insurance appeal 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 complaint or 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 your insurer to explain their reason for refusing your claim in writing. Work through this letter in a logical way- if you don’t agree with what they have said, make notes, 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; however, it is worth asking them to fast track their investigation of your appeal based on your prognosis.
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 your 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. When escalating your complaint to this service, is important to make them aware of your diagnosis and prognosis and ask if they are able to ‘fast track’ the investigation.
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.