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Critical Illness Claim - My Story

Braverose
Posted by

Hi everyone,

I am writing this post in hope I can help others who may be in a similar position.

I was diagnosed with a duodenal NET in December 2017. Since then I had Whipple surgery and the tumour removed successfully. My malignant tumour and graded as 1 and my consultant advised me to inform my insurance. I put in a claim with my insurance soon after for them to then decline my claim under their exclusion 'Having low malignant potential'

I complained to Zurich multiple times but putting it bluntly they didn't care! I knew back then this wouldn't be easy going forward.

I took my case to the financial ombudsman and their adjudicators sided with Zurich within a week. It was then sent higher up to an actual ombudsman. I assumed going to the FO that an ombudsman would review it first but this isn't the case! If any adjudicator declines your claim - complain and take it higher! My mum told me to phone the Macmillan financial team as they had helped her a few years back. They were the biggest help to me in my case & they believed the claim should be paid.

At one point (before Macmillan got involved) I felt so alone in all of this. Your mind plays tricks on you and my insurance tried persuading me that I didn't have what I did have! I thought to myself - maybe I'm wrong, did I REALLY have cancer? because if I did SURELY Zurich would pay... 

Cancer definition in their policy states: 

Cancer – excluding less advanced cases Any malignant tumour positively diagnosed with histological confirmation and characterised by the uncontrolled growth of malignant cells and invasion of tissue.

The term malignant tumour includes: • Leukaemia • Sarcoma • Lymphoma (except cutaneous lymphoma – lymphoma confined to the skin).

The following are not covered: • All cancers which are histologically classified as any of the following: – Pre malignant; – Non-invasive; – Cancer in situ; – Having borderline malignancy; or – Having low malignant potential  

Zurich basically said because I was treated and i'm now 'fine'! They tried every excuse you could think of. Reading their emails and letter infuriated me. They wrote to my consultant numerous times asking the same questions & even questioned his opinion! 

They agreed in their final letter the tumour was malignant but said they wouldn't pay because the grade wasn't high enough. Nothing in there T&C's goes into this detail. It was like talking to a brick wall and was shocking to see the things they come out with.

The FO decided Zurich should pay the claim with interest. I was so happy!! Finally after a year they are paying me! 

Throughout the whole ordeal I felt like I was fighting a loosing battle and creating stress I didn't need after going through such a horrible time.

Many times I felt like giving up. Zurich made me feel like I was wrong and at points didn’t even have cancer when I most certainly did! My mind was playing tricks on me.

It frustrated me as I could imagine Zurich declining claims and people accepting this. Depending on what else is going on you may not have time to fight against them!

PLEASE DO! If you KNOW you are right you most likely are. 

Macmillan financial guide will be able to tell you if you have a case or not. Fight it to the end and don’t believe you can’t beat the big man. I did!! 

I can't stress enough how upsetting the whole ordeal was. To be told at 24 years old you have a rare type of cancer and then have to deal with this for over a year later really tested my mental health. I should of been able to move on with my life after having cancer and avoid being stressed but Zurich made this impossible. 

I might be on my own on this one and insurance companies pay out on most claims. I wouldn’t be surprised if they did this to other people like me.. Another thing that annoyed me was they were wasting Macmillans time and my hospitals time. The hospital are treating people and saving lives like they saved mine! 

It took 13 months to receive payment but worth it. The feeling of beating them was amazing - sticking it to the man 

The Macmillan team did such a fantastic job and I can't thank them enough. Without them I wouldn't be writing this now.

Cheers

Rosie x

daloni
Posted by

Wow! That’s so brilliant, . You are amazing and so brave to keep going in the face of heartless bureaucrats. You really have lived up to your user name. Well done you and well done Macmillan. I hope your story is read widely. Would you mind if I asked the guys who work on this site if they’d be able to feature your post so more people can see it, perhaps by turning it into a blog? 

Xx

Braverose
Posted by

Hi Daloni,

Thanks so much

Zurich also kept asking about my recurrence rates / chances! - Obviously quite distressing as I didn't want to know!

Yes that is fine with me - I wan't people to read my story and know you can beat them! I wouldn't want anyone to give in when they are in the right

xx

daloni
Posted by

Hi Rosie 

I bet that was awful. One shocking thing is that it was another human being writing those letters. I wonder how they sleep at night? 

I will ask the admin team to get in touch. In fact, why don’t I just tag them here? 

- would you be able to help get this important lesson a wider readership please? I think it’s really important as not everyone will be as persistent. 

Pip pip! 

Xx

Braverose
Posted by

Hi everyone,

I thought I'd write a little post as an update.

As my family & myself were so grateful for everything Macmillan has done for us we hosted a Brave The Shave.

You can read the full story here and see photos of before & after

https://www.justgiving.com/fundraising/braving-the-shave

We raised an amazing £3246 + gift aid of £418.75 - we are still some receiving donations as well

We had a fantastic night and people could openly talk about cancer. Not in a sad way but how Macmillan have helped them themselves or someone they knew. 

I also now feel at ease as I feel like my cancer journey has finally come to an end - crazy right? but forever grateful 

Thank you everyone who has read my posts & commented. I hope life treats you all well 

Love always Rosie xx

daloni
Posted by

That’s absolutely brilliant ! Well done! 

Xx

Clarke79
Posted by

Hi - please could you accept my friend request so I can ask you a question. Regards     Ben.

Clarke79
Posted by

Hi Rosie - my name is Ben. I’m so glad I found this article as I am going through exactly the same thing with my insurance company. Please could you get in touch with me as I would like to know how you progressed things so I can do the same.

Hope you get this.

Kind regards     Ben.

daloni
Posted by

Hi Ben

Sorry you’re having issues too. I am going to flag Rosie so the system sends her an email so she knows you’d like to get in touch. Hopefully that’s helpful. 

- hope you’re doing ok. And I hope this reaches you. 

All the best 

Clarke79
Posted by

Thats great thank you!

Braverose
Posted by

Hi all,

Sorry i turned my notification off! (my bad) 

All in contact now and happy to help

Rosie xx

daloni
Posted by

Great! Over to you two,

It might be best to make friends in the community (there’s a button somewhere on this page) and then you can exchange emails or whatever. 
All the best 

Clarke79
Posted by

Thanks Daloni.

Helob
Posted by

Hi Rosie

Im from Ireland  and was googling some information about declined claims and your post came up.I  have be declined my claim as well and i was hoping for some advice.My cancer was a Gastro intestinal Stromal Tumour Grade 1 in the ampulla of vater for which i also had a whipples procedure.They declined mine because they said it was non invasive the nodes  were clear and had no mucosal invasion however the histology showed that it originated in the ampulla and grew into the duodenum dimensions were 2x3x4 cm.it also had a pushing border into the pancreatic parenchyma ! whatever that means ?in the ct report it states it is an ampulla tumour which extends to the duodenum so i figured that shows invasion .I have written to the surgeon to get his opinion and Im meeting with the GP to see what she says before i appeal it.

what do you think any advice or am i wrong in my opinion of invasion.

any help greatly appreciated 

Helob

Clarke79
Posted by

Hi - It’s very upsetting to see an insurance company try and wriggle out of paying what they should again! 


I was in the same boat a few months ago and found this thread and the following things helped me make a successful claim in the end..

1 - Talk to Macmillan and tell them what’s going on. They are great and with assist you and talk to your insurance company.

2 - Make contact with your insurance company informing that Macmillan are helping and state that you do not need the additional stress of this on top of a major health issue. 

3 - Mention that you will chase this to the end and will contact the insurance ombudsman.

4 - Dismiss all of their excuses! You don’t get more invasive than a tumour growing inside your body! 

It’s also worth mentioning that we have done the same and received our claim plus interest for all the delays.

It makes me so angry that insurance companies can treat people like this. It’s disgraceful. Good luck with this and don’t give up!