The 22nd annual Pro Bono Week takes place from 6 to 10 November 2023. Pro Bono Week offers an opportunity to recognise and support the voluntary contribution made by the legal profession across the UK in giving free legal help to those in need. This year’s Pro Bono Week theme is “changing lives through pro bono”, something that the Stewarts’ Legal Service and Pro Bono team do on a daily basis.
In this article by paralegal Insaf El-Jaafari, we look at how the Pro Bono team assisted a patient to receive a life-changing sum of money from an insurer who initially rejected their claim.
As part of the Legal Service, we assist patients by reviewing insurance policies to establish eligibility, and support patients in making claims. Insurance policy documents are frequently lengthy and confusing, with numerous conditions and exclusions. Unfortunately, the process of claiming under these policies can be time-consuming and sometimes overwhelming for patients focusing on rehabilitation following serious injury or illness and their families. However, where successful, the money from claims can provide important financial support to patients at a difficult time, as highlighted by the case study below.
Stewarts assisted AP, who was referred to our Legal Service following a spinal cord injury, and his family secured more than £250,000 in insurance pay outs after the insurers initially rejected his claims.
AP and his son were involved in a road traffic accident in which AP sustained a C5 complete spinal cord injury, rendering him tetraplegic.
AP’s son was also injured in the accident. He sustained a spinal fracture of his left tibia and underwent surgery.
After the accident, AP’s wife contacted their insurers to claim support after AP’s incident. However, they told her AP was not insured as “the bike was over 250cc”.
Understandably, AP and his family were devasted to hear that AP was not entitled to receive any payment under their insurance policies. This was extremely upsetting news for them, given how significant the money would be in support of AP and his family during his recovery and beyond.
After a meeting with AP, Stewarts reviewed the policy and contacted the insurer on AP’s behalf to discuss the situation.
Permanent disability, work benefits and hospitalisation
After reviewing the policy, we found that AP’s policy provided benefits in respect of “accidents which within 24 months results in death, permanent disability or hospitalisation exceeding 24 hours”.
We advised and assisted AP in making a claim on the basis of permanent disability and hospitalisation. In doing so, we communicated with the insurer numerous times.
We initially requested that the insurer reconsider their decision not to cover AP’s accident. We obtained AP’s file from them, including the medical report the insurer had obtained so that we could review this.
Having reviewed AP’s insurance file, we took instructions from AP. We set out to the insurer the full extent of AP’s ability to move and the difficulties he faces throughout a typical day due to his injuries. We also asked AP for a detailed breakdown of the extent of his ability to perform any of the functional assessment tests detailed in the insurance documentation.
We emphasised to the insurer the restrictive and vague nature of the policy wording and challenged the insurer on this.
The insurer took the content of our letter on board but still required confirmation from a medical expert. AP’s treating consultant was contacted to obtain this.
Upon review of the treating team’s letter, the insurer confirmed that AP was entitled to the maximum benefit payable under the hospitalisation criteria. This provided AP with a sum of £13,725. Also, as it was confirmed AP would be unable to return to work, he was eligible for a further £100,000.
After several months, during which we liaised with and chased the insurer on AP’s behalf, the insurer informed us that the medical report had been received and that AP qualified for cover under ‘total permanent disablement’. As a result, the insurer immediately settled AP’s claim in this respect, and he received a further sum of £150,000.
The insurer had initially rejected AP’s claim, but after receiving the assistance of our free Legal Service, he received a total of £263,725 from his insurer. The process took just under a year and enabled AP and his family to concentrate on their recovery while we dealt with his insurance claim.