A serious injury or illness can change your and your family’s lives forever. In this article, we set out some tips for establishing if you have an insurance claim following your injury or illness and how to bring a claim if you do.

When we first meet people who have sustained a serious injury or are critically ill, one of the first things we do is advise them to check their insurance policies to see whether they benefit from any no-fault or critical illness insurance cover.

Insurance claims can be difficult, and policy wording can be tricky to understand. It can be devasting if a claim gets rejected. We have prepared some tips for checking your policies and making a claim, as well as some information about how to challenge a rejected claim.

Where do I look?

Insurance policies come in many shapes and sizes. For instance, some people have income protection policies through their work or separately if they are self-employed. These can provide monthly payments in the event of a serious injury or illness.

It is important not to look past your home, car and travel insurance as these may include critical illness or personal accident cover. Some people are not even aware they have insurance as a benefit attached to their credit card or bank account or as a perk through their job.

If you are unsure whether you have an insurance policy or you cannot find the policy, do not give up. You can simply email the company you think the insurance policy may be with and ask them to send your policy and any accompanying terms and conditions. This will usually include a claim form and instructions on how to claim.

Make sure you are aware of time limits. Often, insurers require claims to be made within a certain timeframe. If you are not sure if there are any time limits, ask your insurer to confirm or clarify the position.

Check all your documents (twice)

When completing the claim form, tick the relevant part to say you want to see a copy of the GP or consultant’s report. This will enable you to review it and iron out any inconsistencies. They may have got something wrong, not included all your symptoms or made an error in the report, which may cause a delay in the insurer considering your claim. It will likely be more cost and time-effective for you to highlight inconsistencies and fix them with the doctor before the report is sent to the insurer.

Get your ducks in a row

Read the policy thoroughly. It is important to request and read all the terms and conditions and accompanying policy schedules, as the ‘fine print’ may hold the key to unlocking your claim. Yes, these are long and often repetitive, but careful reading at an early stage will reduce the chance of a rejected claim.

Examine the definitions carefully

Unfortunately, many people who sustain an injury or are diagnosed with an illness find their condition is not included in the list of illnesses under their critical illness policy. However, you should examine all the illnesses covered in the policy and look up their symptoms. If your symptoms match another illness that is included, you may be able to argue that you should be able to claim under that policy provision instead.

For example, transverse myelitis is a rare condition that can often lead to the loss of movement in both legs. In our experience, this is rarely covered explicitly in insurance policies. However, its symptoms are often similar to paralysis or ‘loss of a limb’. Where loss of a limb is covered under a policy but loss of use of a limb is not, it may also be possible to argue that loss of use of a limb is effectively the same as loss of a limb; we have argued this successfully in the past. Depending on your insurance company’s definition and whether your symptoms match any of the listed conditions, you could then make your claim under this other defined condition.

Multiple claims

Often, you can make multiple claims under one insurance policy. For example, some critical illness policies will pay a lump sum for your injury and a fee for the number of nights you spent in hospital. Moreover, you may be able to claim for Total Permanent Disablement, which we have written a separate article on here.

Build your case

Include as much supporting evidence as you can. You can get your full medical records for free from your GP or the hospital you attended, though obtaining your own medical evidence to support your case may be beneficial. You could ask your GP or treating consultant to prepare a letter for your insurer. However, your GP or consultant may charge a fee for writing a letter, and many insurers ask for a compulsory report from your GP or consultant (which you may have to pay for in any event). Therefore, you should ask them if they would consider doing it for free or at an agreed price in advance.

If you decide to obtain your own medical evidence, you should send your consultant or GP the precise wording from the section of the policy that is relevant to your claim. This will reduce the likelihood of the insurance company being pedantic and overly prescriptive that your condition does not match the precise wording.

After your GP has completed the letter/report, ask them to send it to you first so you can review it and iron out any inconsistencies. They may have got something wrong or not included all your symptoms. It is more cost and time effective for you to highlight inconsistencies and fix them before it is sent off to the insurer.

Know your rights

If your claim is rejected, you should make a complaint to the insurance company directly. An insurance company generally has eight weeks to consider your complaint.

If you are still unhappy with their decision, you can make a complaint to the Financial Ombudsman Service (“FOS”). The FOS is an independent and impartial service that aims to settle disputes between consumers and financial businesses.

It is important to follow the complaints procedure set out by the insurance company when you are challenging a rejected claim. The FOS will not look at your complaint until the insurance company’s own complaints procedure has been exhausted.

Be patient (to an extent)

Some policies require that a specific time period elapses (often 12 months) before they will pay out on a claim. This is often because the insurer and the medical team need to be sure your injuries are permanent. If you have suffered a serious and permanent injury, you can ask for payment earlier than the set time frame. In this situation, it would be advisable to obtain medical evidence confirming you meet the policy definitions now and you will continue to meet them in, for example, 12 months’ time.

Success stories

These are the steps we take to assist patients through the Legal Service. We have seen many successes over the years, some of which you can read about on our website:

• Client secures £132,000 insurance payout following fall from a ladder
• Pro bono team assists patient with insurance claims following brain injury