Pax Breech Of Contract/ Mistakes With Claims

Discussion in 'Army Pay, Claims & JPA' started by MRS JTAC, Jul 2, 2011.

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  1. This is a brief summary of the ongoing problems/breech of contract that I have experienced since submitting a claim to Chartis for my husband's permanent disabilities.
    My husband was injured in Iraq in late 2006. We submitted a claim for permanent loss of vision in one eye in early 2007. The initial offer of 'settlement' was for £30,000, which later increased to £45,000. I complained and a senior member of staff apologised for the 'mistake' in calculation and offered £121,500. We rejected this and finally settled on a figure of £129,000 in late 2007, based on an 86% loss of vision. I was later informed that Chartis (formally AIG) no longer use the same CMO a Dr St*** and the member of staff who assessed the claim Ela**e Sa**er had also left the company after further mistakes emerged.

    In late 2008 my husband was diagnosed with a head injury as a result of the same accident, and we submitted a claim under Section B item 15 of the policy (permanent disability not otherwise listed.) Following many more mistakes the claim was assessed by a Ing**d Woo***rd, Consumer Lines and Auto Claims Manager in July 2009. Their CMO said that in his opinion there was sufficient evidence to suport a figure of 5% global disability. A figure of £7,500 was offered for the disability. I told them that their use of percentage of global disability breeched their contractual agreement; they disagreed. We appointed a solicitor who agreed that they had incorrectly assessed the claim. The complaint went to the FOS who upheld our complaint. They were told to reassess the claim in line with the terms and conditions of the policy, pay us £250 compensation for distress and inconvenience and pay 8%p.a on the final settlement figure.
    The policy wording was changed in the February 2010. I have complained separately to the MOD about this, as the change in the policy terms and conditions have not been communicated to policy holders. The person I spoke to was not aware of any change to the terms and conditions and are looking into this. The wording of the policy at the time of the accident stated;
    'We will pay the benefit under item 15 of section B (permanent disability) by assessing the degree of disability suffered compared to those permanent disabilities specifically mentioned in that section without taking account of your occupation.
    The terms and conditions made no reference to using a 'global disability' figure.
    The claim is still ongoing. My husband has recently been medically discharged oin the grouds of his injuries. Chartis have now agreed to pay our legal costs which to date are some £5,000+. They have requested a copy of all medical notes that relate to my husband a copy of his personnel file, a copy of his diary....Chartis have also instructed their own solicitor to represent them.

    My concern id that in a recorded phone call to Chartis in 2009, I was told by a senior manager that all claims for permanent disabilities are assesed using the global disability and applying this figure as a percentage to the policy.

    The above is a very brief overview of what has been a very stressful claims process. I am happy to answer any questions that anybody reading this may have.
  2. Any PAX experts out there?
  3. There are - but I think they work for PAX, so probably aren't in a position to comment.

    Although as a contracts expert, I don't see how a wording change in 2010 has any relevance to an injury sustained in 2006 - unless I am misunderstanding something. Just as you can't buy health insurance now, and claim against it for an injury you (knew you) had before you took the policy out.
  4. Depends on the insurance contract: some are on a 'claims occurred' basis, others are on a 'claims made' basis. PAX Bloke on here tends to give very helpful advice and is not just a drone of the CHARTIS company......however for CHARTIS this insurance programme has been an unmitigated disaster with seriously high loss ratios (think 10 years of premium income gone in under 1 year's worth of claims). They are not a charity and their primary responsibility is to fulfil their side of the insurance contract to the letter: their fiduciary duty to their shareholders prevents them from doing anything else in most circumstances.
  5. The_Duke

    The_Duke LE Moderator

    There are many types of systems/scales used to assess disability which falls outside of the limited type of scale of benefits (ie loss of or loss of use of a limb) which can be shown on a relatively simple PA policy.

    In an ideal world the system to be used should be clearly stated in advance to avoid the rather vague wording of "We will pay the benefit under item 15 of section B (permanent disability) by assessing the degree of disability suffered compared to those permanent disabilities specifically mentioned in that section without taking account of your occupation." This phrase tells you that the claim will be assessed, but not how.

    It would be much better to explain the system of assessment to allow all concerned to know how their claim will be handled. The problem lies in that these various systems are specific to types of injury, and the symptoms that arise from them. I have linked to some examples for stroke victims below - a stroke may show similar symptoms to a head injury.

    Stroke Scales Overview | Internet Stroke Center

    So here lies the problem - you want to use the scale that pays you the most, insurers want to use the scale that pays you the least because they are losing money hand over fist on this account. They are not in breach of contract, you are in a negotiation with them over a non-standard claim.

    Don't worry though - the FOS will always find in favour of the individual rather than the insurer, no matter the facts!
  6. Thank you for your comments. In relation to the wording change I am aware that this does not effect our existing claim. Chartis did give the FOS the terms and conditions of Feb 2010, and try to make out that they were not breaching the contract though! I raised the point about the change to the terms and conditions of the policy because the policy states that all changes in the terms and conditions should be agreed by the 'plan co-ordinator' (the MOD). There have been no updates about any changes, and the person that I have spoken with from the MOD who deals with Pax Insurance was not aware of any changes.

    I am very aware of the huge losses that Chartis are making on this policy. The changes to the terms and conditions should have been communicated to policyholders so that they could make an informed decision as to whether they wish to continue with their cover.

    We have complained to the FOS for a second time about Chartis. The FOS have requested a copy of the file.

    I currrently know of two other people who claimed under item 15 of section B who have also had their claims assessed using the global disability figure. In addition to this, two very senior members of staff told me in 2009 that how my husband's claim was assessed was how all claims or item 15 were assessed (I have a copy of the phone calls after doing a suject access request). Stev* Agutte* who is now the Executive Director Claims Europe also failed to see how they had incorrectly assessed the claim.

    The claim for my husban'd head injury is still ongoing. Chartis have requested to see all of my husband's medical records, which we have agreed to, but also a copy of his diary, and a copy of his personnel file. My husband sat his medical board in May this year and was recommended for a medical discharge on the grounds of his injuries from 2006. Chartis have even said that they may wish to put questions to the people who make the decision about the medical discharge.

    In additon to all the above, Chartis have 'lost/misplaced' my husband's file, sent information to the incorrect address, got the name of the disability wrong, and recored on my husband's file that he had lost his leg (he has both)!

    I would like anyone who has claimed for a permanent disability not otherwise listed (item 15 section b) to contact me as I am trying to gather more evidence to take this complaint to the FSA.

    Shame on you Chartis. Our troops deserve far better!
  7. Thanks for the response from The Duke. Fistly I would like to point out that Chartis made a 'final offer' for my husband's head injury in 2009. The 'final offer' was for £7,500 based on using a figure of 5% global disability and applying that to the total sum assured (£150,000-15 units). The claim was not assessed in line with the terms and conditions of the policy. Our solicitor wrote to them in 2009, telling them that they had breeched the contractual agreement, and the FOS upheld our complaint in September 2010 that they had breeched the terms of the policy.

    It should have been quite simple. Chartis' CMO a Dr Gavin We**-Wilso* of Rood***e Medical applied a figure of 5% global disability to my husband's head injury in July 2009. We neither agree or disagree with this figure. All Chartis had to do was ask him his opinion as to which other disability from the table of benefits he felt represented a similar global disability figure.

    An instruction has recently been agreed for the opinion of a neuropsychologist on a joint expert basis. Chartis are asking the expert 'please assess the degree of permanent disability compared with other items in section B...'

    Chartis have refused on numerous occassions to answer how they will assess the claim if the expert cannot make the comparison, and what global disability they attribute to each item on the table of benefits.
  8. Hi Mrs JTAC, I've had serious problems with AIG (CHARTIS) I was MD in 2007, I got injured playing a sport, where I was discharged in 2007, I started the claim in 2005, I went around in circles for 4 years, going to the FOS about what they offered myself, the FOS did not up hold my claim and had to suffer with a claim of 12% instead of 100% as I am unable to work and enjoy the things I loved to do.

    I will help, if you need me, just PM myself and hopefully put these people in their places, I served for 20 years and I'm on a

    Good luck
  9. Thanks. I will PM you later.
  10. Hi, I was made to see a specialist for PAX (AIG) CHARTIS, I saw this person, who claimed I could return to work if I had a certain operation, which I showed my specialist and he could not believe this, I need a total knee replacement, but that is not 100% certain, as I have the habit of contacting infections straight away, or I lose a lot of blood, so I'm told to sit tight and hold on, which is not what their specialist had said, these people seem to have human X-ray, or more like their paid for their poor
    response and that's final - What a load of rubbish, they take our money but never look after you, a bit like the VA
  11. Hi Mrs JTAC, I was wondering if you might have any knowledge about a payment pax makes when someone in the forces gets medically discharged as a result of an injury someone has claimed for in the past. I have heard from some of my colleagues that they were paid £2,500 per unit when they got medically discharged. I am going to be medically discharged as well in June this year as a result of an injury I sustained in Afghan back in 2007, but when I called the insurance provider(pax)to inquire about this medical discharge payment, they told me that they only pay out if someone is medically discharged within 2 years of the accident. What I am confused about is that I know a few people who have received the payment even though they have cut the 2 year 'limit'. And also there is nothing written about this 2 year limit thing in the registration pax brochoure. Any feedback is much appreciated.
  12. Rajen,

    You need to ask PAXBloke about that, not MRS JTAC.
  13. Hi Rajen,

    The two year limitation is covered in the first paragraph on p. 13 of the Policy Document contained alongside the enrolment form in the PAX brochure.

    'if, during the period of cover, you suffer bodily injury which, within two years solely and independently of any other cause, results in death, permanent disablement, specified burns, specified fractures, hospitalisation or flesh wounds, we will pay the total sum insured.'

    Not that the maximum payable under Section B is £20,000 per unit. So even if you qualify for a payment under Medical Discharge, if you have received £20,000 per unit already, no more will be paid.

    However, when it comes to claims that go beyond the two-year limit, each will be judged on its merits. For example, if someone was undergoing continuous treatment, which meant they were MD'd after 30 months then a payment might still be made.

    If however, someone went back to work, but were subsequently discharged, then they may not qualify.

    I suggest you go back to the claims team and ask that they look at your case in more detail. Any problems then you can normally find me in the Finance thread under the PAX sticky :)

    Kind regards,

  14. What is the procedure to take unresolved issues to the Insurance Ombudsman?
  15. The_Duke

    The_Duke LE Moderator

    1. Make sure you have followed the complaints procedure within the insurance document. They are required by law to show this. You need to have allowed sufficient time for this to be carried out, and also be able to demonstrate that you have engaged in the process.

    2. The offer (or declinature) from the insurer will tell you what to do if you are still not satisfied, including escalation to the Financial Ombudsman Service (FOS). Follow the instructions.

    3. Don't bother jumping straight to the FOS without exhausting all avenues of enquiry with the insurer, as they will just refer you straight back to them anyway.

    Just to help you out, I have shown where to find the information on their information pack- Page 9, bottom of the first column going into the top 1/3rd of the centre column:

    FOS page here: