Critical illness insurance gives financial protection in the event that you are no longer able to work or carry out your normal day-to-day activities due to a long-term illness or disabilities.
Critical illness policies provide cover for specific conditions, and nearly all policies also provide cover for “Total and Permanent Disability” (TPD). The TPD section of the policy is often the section that chronic pain sufferers will use to make a claim.
There are three different definitions of TPD as follows:
It is very important to check on your policy Schedule which definition of TPD applies to you
It is not uncommon for insurance companies to be reluctant to pay out on policies of this nature, even though the criteria needed to fulfil the payout are straightforward. However, when the illness in question is a chronic pain condition such as fibromyalgia, ME or CFS, they tend to be even more cautious about paying out and will often insist that their customers try all avenues of treatment before agreeing that they have fulfilled the criteria for an insurance payout.
Similarly, where one has an ill-health pension, it can prove difficult to receive the pension when the illness in question is a chronic pain condition. However, Brian Barr Solicitors are experts in critical illness and ill health retirement claims and can help you by obtaining the evidence you need to prove to the insurance company that you meet their criteria for a payout.
Every critical illness policy will have its own definition as to what qualifies as a critical illness, and which illnesses are covered by critical illness insurance, so it is important to carefully check your insurance documents before claiming. However, the most common critical illnesses and disabilities include:
However, when a claim is made as a result of a chronic pain condition such as fibromyalgia or CRPS, it can be difficult to prove that these conditions will prevent you from working, so it can be more difficult to receive a payout from your insurance company or pension provider. But that is where we come in.
Read more about how we support client throughout the UK to claim compensation for their injuries or chronic pain conditions. Brian Barr Solicitors consistently achieves great results and high compensation amounts.
44 year old nursery nurse LB from Basingstoke developed the chronic widespread pain condition fibromyalgia and it stopped her working. LB was not fit enough to return to work and she was dismissed on ill health grounds two years after the accident.
LB had a critical illness insurance policy entitling her to a lump sum if she became permanently unable to work in her own occupation as a nursery nurse. Her insurers rejected her claim, she continued to pursue it, but to no avail.
LB eventually approached Brian Barr Solicitors. We looked at the documentation and advised the insurance company that they should be paying out under the policy. They proposed a functional capacity evaluation. We objected because this type of evaluation is inappropriate for fibromyalgia sufferers. An appropriate expert was agreed upon and following sight of his report, the insurance company accepted the claim. LB received just over £150,000, just six months after Brian Barr Solicitors had first been instructed.
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Mrs GL of Norwich was injured in lifting incidents at work and felt she would never be able to work again. She had an accident protection policy and claimed under the Permanent Total Disablement section of the policy. She had to establish that she had sustained accidental bodily injury which within 12 months resulted solely and independently of any other cause in death, permanent disability or hospitalisation.
Mrs GL was insured for £100,000. Insurers said that she had been left with a 15% to 20% global disability as a result of the accidents and they put forward a total offer of £17,500.
Mrs GL instructed Brian Barr Solicitors to act. When we questioned the £17,500 offer, insurers promptly withdrew it.
Mrs GL instructed us to obtain reports from two rheumatologists. These were supportive. Insurers again refused to pay. Eventually they instructed their own rheumatologist and they paid out the full £100,000 plus substantial interest and costs.
I recently received a letter from an Oncology Engineer who was off as a result of a number of illnesses. My answer to him elaborates on the sort of support you can expect from your employer when suffering from critical illness:
Dear Brian,
In 2002 I joined the NHS as an Oncology Engineer. I had four bouts of viral illnesses in 2004. My Manager refused to accept that there was anything wrong with me. In April 2008 I was diagnosed with Polymyalgia Rheumatica and Fibromyalgia.
I am currently off work following three more viral illnesses. I tried really hard to keep working, even turning up to work after heavy snowfalls. I have, however, received little in the way of concessions from my employer to assist me to continue working.
Are my employers obliged to help me with this illness? What sort of help or support can I reasonably expect?
Dear Graham,
Your two medical conditions could be regarded as disabilities under the Disability Discrimination Act, but each case would be looked at individually. To be afforded the protection of the DDA you must be regarded by the Employment Tribunals as someone who has a physical and mental impairment that has a substantial and long term adverse effect on your ability to carry out normal day to day activities. Some people with Fibromyalgia would be regarded as disabled individuals under the Act whilst others would not.
If you are regarded as a disabled individual under the Act your employers would have a duty not to discriminate against you on the grounds of your disability and to consider reasonable adjustments. This could include, for example, allowing you to work from home, work different hours or move you to a location closer to your home. There is no obligation on an employer to make such adjustments – they simply have to consider them.
We recommend that individuals contact the Equality Commission for Human Rights as they are able to offer further assistance. Costs are rarely afforded to the successful party in Employment Tribunal Claims so if you would want to bring such a claim yourself you would either have to fund it or you might be covered by Legal Expenses Insurance, although that is doubtful.
If you have a great deal of sickness absence and it is not reasonable for your employers to be able to cope with that absence, your employers may well be able to go down the capability route with a view to dismissing you.
Brian Barr
We do not endorse any research, studies or sources mentioned within our blogs and comments. Furthermore, we do not endorse any medical advice provided, and would strongly recommend anyone seeking medical advice to contact their local healthcare provider.
Mrs GL of Norwich was injured in lifting incidents at work in June and September 2004. She suffered a back injury which became chronic and she developed fibromyalgia. Mrs GL claimed under her Accident Protection policy. She was unable to work after the second accident and claimed under the Permanent Total Disablement Section of the policy. She had to establish that she had sustained accidental bodily injury which within twelve months resulted solely and independently of any cause in death, permanent disability or hospitalisation.
After obtaining an opinion from an orthopaedic surgeon, the insurance company’s chief medical officer expressed the view (in a letter dated May 2006) that Mrs GL had been left with a 15% to 20% global disability due to the accident alone. Insurers therefore put forward a full and final settlement of 17.5%, namely £17,500.
Mrs GL promptly instructed us to look into the offer. We agreed to act under a Conditional Fee (“no win no fee”) Agreement in which “success” was defined as beating £17,500. We noted that the orthopaedic surgeon had indicated that the fibromyalgia was “very severe and aggressive” and had resulted in these severe physical incapacities. He also commented that he was no expert on fibromyalgia and that a report should be obtained from a rheumatologist or pain management consultant. We suggested to insurers that they should instruct such an expert, but they refused, saying that since it was now twelve months from the date of the accident any further report or examination would not be a true reflection of the level of disability that was present at twelve months post-accident. [This shows that insurers can come up with anything if they want to!]
Because we had had the audacity to question the £17,500 offer, insurers promptly withdrew it. They went back to the orthopaedic surgeon who agreed with the chief medical officer that one would not normally expect fibromyalgia to be the consequence of an accident such as this alone. He agreed the assessment that the accident had produced a 15% to 20% permanent disability. Therefore the offer of £17,500 was repeated in August 2006.
By January 2007 Mrs GL had instructed us to obtain reports from two rheumatologists. These were supportive. Insurers were requested to pay £100,000 under the terms of the policy. They again refused, seeking to pick holes in the two rheumatological reports and again formally withdrawing the settlement offer of £17,500 in February 2007.
The insurers finally decided that they should obtain an independent rheumatologist’s report and they promptly instructed the treating rheumatologist, presumably because he had said that the fibromyalgia had not been caused by the accidents (although he did not give any reasoning for that). So much for an “independent” examination!
Fortunately the treating rheumatologist disqualified himself and a new rheumatologist saw Mrs GL in December 2007. Insurers then appeared to resort to delaying tactics and therefore Court proceedings were commenced against them in February. Shortly after that Solicitors acting on behalf of the insurers conceded that Mrs GL was entitled to £100,000 and interest.
Brian Barr comments “£17,500 was a lot of money to Mrs GL and it took great courage on her part to have us challenge the insurers. They twice withdrew that offer and argued tenaciously against paying any more. We argued just as tenaciously that they were wrong and eventually they went to a doctor in the right discipline who was supportive of the claim. Mrs GL now has the insurance payment that she should always have received plus interest and we have shown again that insurers can be beaten if you know how to tackle them. Mrs. GL also had some kind words to say about us and I am happy to quote them:
What Mrs GL says about Brian Barr Solicitors…
“Without you I would have given up and backed down ages ago, as when you feel like I do, added stress and worry is a nightmare with this illness, but your being there kept me going.
“You are very professional and have worked very hard in achieving two good results for me over the last three years. Unlike many professionals, you have always been there and treated me like a person (human being) and not just a number.
“There is a great stigma surrounding chronic pain/Fibromyalgia from a lot of health professionals and other bodies, but as my cases have also proved, there are some out there who really do understand and indeed care about what people like me are going through, so there is hope yet.
“And with you, a great Solicitor, who has also produced a great team of staff and the health professionals who have understood and shown professionalism and care, I am truly grateful. No words will ever be enough to express my sincere thanks to you.”
We do not endorse any research, studies or sources mentioned within our blogs and comments. Furthermore, we do not endorse any medical advice provided, and would strongly recommend anyone seeking medical advice to contact their local healthcare provider.
44 year old LB from Basingstoke, Hampshire had been a nursery nurse for 22 years until she developed Fibromyalgia. This stopped her working in January 2005. She suffered a constellation of nasty symptoms which made it impossible for her to pursue her demanding employment.
It was initially hoped that LB would be able to return to work but this was not the case. She was subsequently dismissed on the grounds of ill health in April 2007.
LB had a Critical Illness insurance policy. It entitled her to a lump sum payment if she became permanently unable to work in her own occupation as a nursery nurse. It was a policy she had taken out to provide her with some protection should she be unable to work. Given her continuing ill health she made a claim under the policy in January 2006. Insurers duly rejected the claim in August 2006. LB continued to pursue it, but to no avail.
She made no progress with insurers for some 18 months. Finally, in February 2008, LB contacted Brian Barr Solicitors to see if we could assist. She felt she had gone as far as she could on her own and she needed some expert input from solicitors who understood FM. We looked at the documentation and advised the insurance company that they should be paying out under the policy. They started to become more proactive and proposed that functional capacity evaluation be arranged to assist them to review the case. We objected to this. These evaluations are not appropriate for Fibromyalgia sufferers. The appropriate expert to report on LB was a Rheumatologist or Pain Consultant.
The insurance company finally agreed with this and an appointment was made with a suitable expert. In the meantime we requested and received a copy of a report prepared by a nurse instructed by the insurance company. The document was supportive and we insisted that it was sent to the expert.
Following sight of the expert’s report, the insurance company accepted the claim and LB received just over £150,000 in August 2008, just six months after we had first been instructed.
Lyndsey Ryan, Associate at Brian Barr, comments “This case again shows that we can make a real difference on these insurance claims. People often feel that Critical Illness cover just means specific conditions like cancer, strokes and heart attacks but invariably there will be provision for payment in the event of total permanent incapacity, usually defined as being unable to work until normal retirement. Likewise, Accident Protection policies will frequently refer to loss of specific limbs, but will also have a provision for permanent incapacity. Critical Illness, Permanent Health Insurance cover, Accident Protection and Mortgage Protection policies can all benefit FM and other chronic pain sufferers.”
We do not endorse any research, studies or sources mentioned within our blogs and comments. Furthermore, we do not endorse any medical advice provided, and would strongly recommend anyone seeking medical advice to contact their local healthcare provider.
VAT Registration Number 768 1096 04 Brian Barr Solicitors is a trading name of Brian Barr Limited, Co Reg No 7195125 Regulated by the Solicitors Regulation Authority No 537494
