Legal Advice - Insurance Company Not Paying Out!!

Discussion in 'Finance, Property, Law' started by IS Ski Geek, Oct 1, 2007.

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  1. IS Ski Geek

    IS Ski Geek War Hero Moderator

    Last year I had a major accident whilst skiing on a military exercise.

    After a few bouts of major surgery and a few more to go on my knee I recieved compensation through the AFCS.

    I was off work for about 3 months and have been in constant rehab (Headley Court and on camp). Nearly a year later I still cannot run/jog play any sport or carry out much in the way of physical activity (hopefully next year).

    I was paying full amount of injury cover through Abacus for the last 18 years. They have told me not to bother claiming as I did not fracture my kneecap as stated in the policy. The fact that I had ruptured my patellar tendon-ACL-PCL and Itiliol band was not good enough and have refused to pay out.

    Having paid a policy for 18 years at £15 a month to the be told I cannot claim is ridiculous.

    Can someone point me in the right direction for advice which is military friendly and will not bankrupt me if I get fobbed off.

    All I would really like back is the money I have paid them for 18 years to then be fobbed off never having made a claim.

    Any help appreciated.

  2. ISG,

    Because of working for another firm it would be wrong of me to comment specifically. So here is some detail pertaining to a claim under any personal accident plan (including our own). The Company concerned will have specific advice on this in the Policy Documents so please take the time to refer to them as well so this list is not exhaustive.

    1. Read the Terms and Conditions carefully before contacting the company to check if there is a section that may be relevant and the wording you may need to use. Phrases like ‘permanent disability as a result of an accident’ are magic door openers but will need to be supported by medical evidence.
    2. Ask for a claim form - no matter what a company says, you have the right to make a claim and they must consider it.
    3. Complete the claim form and supply the necessary medical evidence - they will probably ask for access to your medical records and this is normal.
    4. If they reject your claim or offer a lower amount then you think reasonable – this should be by letter – write and ask them to formally review it. This they are obliged to do.
    5. If you are still unhappy then the Financial Ombudsman Service is available at no cost: They will only get involved once you have completed steps 1 - 4 but are fair and generally pro-consumer.

    You may wish to seek legal advice but it is not strictly necessary even at point 5 – switching to auto before stage 1 may force the insurance company to go by the letter of the policy and make it difficult for them to negotiate downstream but it’s your call.

    Unfortunately in every accident plan there is a balance between premium and cover – if a given plan covered absolutely everything then the price would be prohibitive. So even after following all these steps, if it isn’t covered under the Terms and Conditions then a company does not have to pay – even if you think they should.

    I hope that is of some help and that you make a full recovery.

  3. PAXbloke's advice is spot on.
    A. Claim and provide the evidence, (don't filter your claims for injury, that's their job!).
    B. Insist on a formal rejection letter
    C. Complain and insist on receiving the management's final letter
    D. Take it to the Insurance Ombudsman

    Just doing this will cost them £600 in fees even if you don't win. Read the fine print, as this will give you the best lead as to winning or not. The Ombudsman is generally considered by the industry to be consumer friendly, but if the policy says clearly that it doesn't cover your specific injury it is highly unlikely you will get your claim paid. That said, if it is badly written and hard to understand you will normally be given the benefit of any doubt.
  4. the_boy_syrup

    the_boy_syrup LE Book Reviewer

    Contact the RBL they will provide advice for you
    I had a mate injured at Akroiri and he sued the RAF the RBL did it all for him and never took a hit as far as I'm aware (he made a donation)