Critical Illness Claim - My Story

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 Stuck out tongue closed eyes

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

  • 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 

  • 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

  • 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!

  • Thanks for replying . Yes it is very upsetting i forgot to add that in addition to refusing me They reduced my cover in half because i gave them an incorrect weight at time of application  i was after having a baby the year before ended up getting septicaemia from a uti so it took a while to get back to normal and lose the weight so i gave the weight i hoped to aspire to  pre pregnancy .They checked it with my GP I had only been with her 4 days before so they had accurate information. I was mortified filling in the application with the rep a man so i knew i was well overweight so i told him the weight hoped to reach. So for anyone reading this give the correct details if you can as they investigate everything!

  • Hi!

    I am sorry you are in this situation but I am glad you found my post. The whole reason I created the post was to help others in a similar situation as me :) 

    The insurance company also declined mine saying it wasn't 'invasive' because it had not spread. That is not the point.. it's that it CAN spread and/or have the potential to spread. I'm sure all the surgeons and doctors across the world would love to tell their patients your cancer will or will not spread but unfortunately they cannot. 

    Also I might add Cancer is defined as a malignant growth or tumour resulting from an uncontrolled division of cells. I think at some point my insurance company said maybe you have controlled cells Joy  should write a book of all the stupid things they said!

    As Clarke79 said - call Macmillan. Speak to their finance team. I wouldn't appeal it with the insurance company as they drag their heels. Just go straight to Macmillan. They are so lovely! They will be able to discuss this with you and advise you if you are in the right or not. Macmillan will act on your behalf. I personally went to the ombudsman but I'm sure Macmillan will help you with this too. Just quickly.. there is two levels to the ombudsman. The adjudicator who was about good use as a chocolate tea pot. Then someone higher who makes a final decision.

    Ignore their excuses.. by the end of it I didn't know who I was talking to. They definitely were not oncologists or anyone in the medical field. They were reading old WHO classifications from the year 2000 or something. You have to question them really.. I found classifications online and read them myself haha. I was 25 years old at the time and felt like I was studying medicine by the end of it haha. 

    In the end Zurich wouldn't even speak to me! Even though I still paid my premiums and have life cover with them. Which also reminds me.. your insurance company should refund you any premiums you have paid since putting in the claim. They refunded me my critical illness AND life cover and also tried to cancel my life cover with them when it should of carried on.. So be alert with them! They are very sneaky. 

    Macmillan will help you with everything. Please let us know how you get on :) 

    Don't give up! I am sooo glad I didn't. Also it's great when you win Wink

    Stay positive. Love Rosie xx

  • Hi Rosie

    Do you think the Macmillan group will support me as im from Ireland? I contacted the Irish Cancer Society and their Advocacy group were to contact me but haven’t as yet!!

    regards

    helen

  • Hi Helen,

    Definitely worth a try! I’m sure if they can’t they will guide you into the right direction of something who can

    Love Rosie x

  • Hi Rosie

    i rand the Macmillan nurse yesterday she was very good she suggested i contact the nurse specialist in the hospital i had the surgery for clarification on the histology results.The issue she explained  is that GIST have pushing borders so the cell membrane is not broken so that may be deemed as non invasive!

     Did your tumour have mucousal or lymph invasion?

    Regards

    Hen

  • Hey,

    No I had no invasion. 
    the definition does not state it needs to have invasion either. They just try and wiggle out of it!!

    My surgeon wrote nearly 10 letters to my insurance company explaining it all and they still didn’t listen to him either! 

    love Rose x