Was the leaking valve treated or diagnosed or on your medical records prior to the time when you applied for the policy which has now been declined?
If it wasn’t, and this might be the point you’re making, how could you have been aware of it and how could you have disclosed it?
If it was, why did you not disclose it
I am an insurance expert. You need an insurance expert at this stage, not a medical expert.
The medical expert opinion will come later if this gets to court.
You say it was discovered 3 years before you join the scheme, but did you disclose it on the application when it asks about previous conditions?
Did you disclose this condition or not? It is absolutely fundamental as to whether your claim will succeed if it gets to court.
It is not to do with whether this leak caused the illness which prevented you flying. That is relatively easy to disprove using expert medical evidence which you already have. Presumably any other medical expert would come up with the same conclusion.
What is extremely relevant is whether they would have taken the risk on in the first place if you had disclosed the leaky valve.
If they can prove that their normal underwriting criteria are that they do not take on people with this condition, then your claim will fail.
This is where it becomes problematical for you because, of course, now they are going to say that had they known about this (if you did not disclose it) they would not have taken the risk on in the first place. You would need to speak to some other insurers or a medical insurance underwriting expert, to find out whether this is a normal risk which is of concern for them or not and use that evidence to support any claim.
If you did disclose the condition on the application form, they took the risk, and even if the condition caused the illness which stopped you flying, they still have to pay.
Because of the amount of money involved, they are not likely to give up without a fight and this could be potentially quite risky if it gets to court because if you lost for any reason, you could end up paying substantial legal costs.
Can I clarify anything further for you?
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I don’t understand. You said “the application form does include a questionnaire about previous condition” but then you said “the insurance company do not want to know any medical details”.
What is the exact wording of the polity terms and conditions with regard to pre-existing conditions?
Thank you. That’s clear now.
The terms of the policy are clear enough, they won’t pay out if a pre-existing condition causes the disability or death. That is the argument.
It is not uncommon for income protection policies to be underwritten at claim stage not application stage and everyone thinks that they have automatic acceptance whereas they do not because of clauses such as the one here.
If the leakage caused your condition, then you have no claim. Your expert says that it did not.
If you are going to take them to court, you are going to need medical evidence which confirms that the leakage did not cause the illness. The more opinions that you have on that the better because the insurance company are going to come up with expert evidence which says that the leakage can cause the condition.
If they will not roll over pay up, then you have no option but to take them to court.
When did you send it? How did you send it? Was it attached?
No doubt, they will come up with medical evidence which proves the opposite and hence, what you need is either a heavier expert’s opinion or a weight of opinions in your favour.
If you are researching this, it would also be worthwhile pulling out the opinions which are not in your favour because then you know what you’re up against.
This is decided on the balance of probabilities gets to court so the judge only has to think that evidence in favour is slightly more credible than evidence not in favour and your claim would be upheld.