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tdlawyer
tdlawyer, Lawyer
Category: Law
Satisfied Customers: 1096
Experience:  11 years experience of general practice.
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I have a critical ilness insurance policy which I purchased

Customer Question

I have a critical ilness insurance policy which I purchased in 2007. I purchased it from Nationwide (acting for Legal and General), and I was assured tha the policy would pay out if i was ever ill enough to be off-work for a significant period. I have been off work due to a chronic pain condition now for nearly 6 months (and facing the likelyhood of my wages being cut to 50% by my employer). I have been informed that any claim I make against the critical illness policy will be refused as my particiular condition is not covered.

I am concerned on the following issues :
1) The policy was originally mis-sold to me, as clearly it does not fully cover all ailments that could keep me off work for a significant period.
2) That the policy is not suitable for me (or any other non-medically trained person) as I could not possibly be expected understand medical terminology of thepolicy
3) That I could not be expected (as I am non-medically trained) to understand that their might be other medical conditions that are not covered by the insurance, but which would have a similar work/life impact.

Both Legal and General and Nationwide are refusing to discuss with me any complaint I am trying to make, and keep pushing me back and forth between help-lines.

WHat can I do.
Submitted: 3 years ago.
Category: Law
Expert:  tdlawyer replied 3 years ago.

tdlawyer :

Hi, thanks for your question. My name isXXXXX can help you with this.

Customer:

hi

tdlawyer :

Hi.

Customer:

I hope you can help - my wife and I are desparate now - we face loosing our house.

tdlawyer :

Can you tell me whether you received advice when you purchased the policy?

Customer:

only that it would cover me if ever i was unable to work due to illness - I was not given detailed medical advice.

tdlawyer :

But were you given advice by anybody when you purchased the policy? I ask, because sometimes, you can buy a policy without taking any advice from anybody.

Customer:

i was not given any advice by anyone

Customer:

I was in the process of agree a mortgage and as part of that mortgage application, life insurance and critical illness cover were discussed

tdlawyer :

Who discussed the critical illness cover with you? Was it a mortgage broker?

Customer:

If I recall correctly it was - although it might have been a separate insurance advisor at the same Nationwide Branch.

tdlawyer :

Okay. In that case, you may very well have a claim against the broker, if they should have given you appropriate advice. If they will not now engage with you, then you can refer the dispute to the financial ombudsman service.

Customer:

ok - problem is that will take years :-(

tdlawyer :

The ombudsman can make awards based on principles of fairness, without necessarily following the strict letter of the law. The ombudsman is , therefore, more generous to consumers, like yourselves, then the court would be.

tdlawyer :

The ombudsman service should not take years. It is possible, also, to have complaints expedited, which, given the potential loss of your home, is something I'm hopeful that they would agree to do.

tdlawyer :

The only alternative, is to issue proceedings at court, but as I mentioned, that system is not as favourable to you as the ombudsman would be.

Customer:

ok - how best to engage with the ombudsman - i have about 6 weeks to prevent me having to sell my house. and I am not looking for a refund of my premiums, I need them to honour the claim on the basis of what I was originally promised

tdlawyer :

Yes, the ombudsman can force them to honour insurance policy.

tdlawyer :

That is what you need to state to the ombudsman, that you want, in your application complaint form.

tdlawyer :

Have you looked at the ombudsman website about how to bring a complaint?

Customer:

ok - the problem is the policy itself is unfair, as it is impossible to understand without a medical training - upholding the policy will in itself be pointless/

Customer:

i will have a look at the ombudsman web site, and go from there. It is worth also trying again to engage with Nationwide complaints ?

tdlawyer :

That is why the ombudsman is always the better approach. They can make a decision, and require the insurer to do something (including pay out) even if not strictly in accordance with the letter of the law. Therefore, you would argue that where insurer has entered into a policy so deliberately confusing, a consumer ought to be entitled to read the documentation a certain way, and require that level of cover to be applied. Obviously, in court, it would simply come down to the contract said.

tdlawyer :

This is why the ombudsman route is undoubtably the best route, and you might want to ask them to expedite the complaint, on the basis of your financial position and the potential for losing your home.

Customer:

ok - thank you for your help - i will go via the ombudsman.

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