Shafted by PAX - Suggestions?

Discussion in 'Charities and Welfare' started by ShoghunUK, Nov 18, 2010.

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  1. I am currently a serving soldier (awaiting my medical discharge date from Glasgow) and am seriously disabled as the result of an accident in 2008. Whilst in Headley Court, an independent financial adviser told me I had a valid and strong claim for PAX, something I hadn't even considered.

    To cut long story short, I submitted my claim with all the evidence needed. PAX is actually Chartis Insurance UK Ltd and they initially told me that because I was paralysed, I would have to wait about a year to make sure I didn't miraculously get better. My doctor told them that that was not going to happen and the claim process went through it's slow process. Chartis really procrastinated, saying that MOD wasn't sending any medical notes, etc. Eventually I had a letter saying that they weren't paying the claim as I didn't really have an accident. Stunned at first, I sent them evidence that other various bodies considered it an accident (AFCS results, doctors notes etc). They went quiet for about 2 months and then sent a final letter saying that it still wasn't an accident and they weren't going to pay a penny.

    I contacted the Insurance Ombudsman and asked what was the maximum amount they could enforce should they find in my favour. They told me that the most they could make Chartis pay is £100,000. I am on tier 15 in PAX and according to their payout sheet, I would be entitled to £225,000 (lowest) to £400,000 (highest), due to the nature of my injuries. By forcing me to go to the Ombudsman, they have practically guaranteed that they will save over £100,000 in compensation, and that's only IF they find in my favour.

    In short, because I don't have any missing limbs or significant deformity (spinal cord is messed up), they have managed to deny my claim knowing that they could save money even if I won through the only means of redress I have. Although I am stoned most of the time (lots of morphine to control my pain), even I can see how obvious this is and I am furious because I am impotent to do anything.

    Does anyone have any suggestions on what I can do?

    I wish there was some way I could advise those serving and spending £60 a month on PAX to save their money and find a more reputable insurance company because unless they lose limbs, I fear the same will happen to them. My wife is livid with rage and wants to contact the press, but I have told her I doubt they would be interested and as a soldier, I cannot talk to the press anyway. She just wants to lash out and I can't blame her.

    Obviously, my case is with the ombudsman now, but I am inquiring is there any other course of action I can take?

    Sorry if I have posted this in the wrong area.
     
  2. B_AND_T

    B_AND_T LE Book Reviewer

    Not much help I'm afraid but after breaking my arm I had a payout within 2 weeks. Keep at them.
     
  3. Finding a decent solicitor is a good start.

    PM sent.
     
  4. The_Duke

    The_Duke LE Moderator

    Firstly, if you have not already done so make sure you follow the complaint procedures shown on the PAX certificate. They are not just there for show, and trying to jump straight to the FOS will not work in your favour. They will just revert back to stage 1 of the complaints procedure.

    Secondly, all insurers (including Chartis) are very tightly regulated and the FOS is very customer biased. If they (ie Chartis) think that you do not have a valid claim, then they will need to defend that position to the FOS. The £100k limit is not good, but a decision of that size against an insurer by them will not be good news for the insurer. The FOS may well give an award of £100k, but a strong recommendation to pay in full - that is a recommendation that an insurer would ignore at its peril.

    Lastly, and this is where it gets emotional, your PAX policy only covers you to the extent of the limits, terms and conditions in the policy. Without knowing the full details of your case, no-one on here is able to comment on whether you are right, or Chartis are.
     
  5. Can only signpost you unfortunately , but glad to do so: Would the SPVA be able to help you? Or perhaps your local Citizens Advice Benefits and Money Advisor ? They claim to provide a welfare rights and money advice service to serving UK armed forces personnel, ex UK serving armed forces personnel, and their dependants. In some cases , those "CAB BMA" staff are either qualified lawyers or if they're not, they have qualified contacts. You can find your local TRBL branch, online, and they may be able to offer help. At worst, you could get support with an appeals process, and, sometimes, a bit of clout from large influential organisations can add some weight to these things. Definitely worth a punt, mate.

    Good luck.
     
  6. samm1551

    samm1551 Old-Salt Book Reviewer

    As a financial Advisor I would say providing you have made complaints the correct way (ie pax then fos) then I would get a good solicitor.

    If I was your wife I'd want to wait until you'd been discharged and then go to the papers because I would be pretty upset too.

    Whatever happens I hope the outcome befits the circumstances.
     
  7. Thank you for your post.

    I have been through the process completely. I even managed to get my specialist and the SMO to write a letter to them informing them that in their medical opinion, the Chief Medical Officer of Chartis is talking poo when he listed the reasons for not paying up. My final letter from Chartis included the phrase, "our Final Response" which made it pretty clear that they were not going to consider any other evidence. The FOS is my penultimate call. I am hoping that they recommend the full payment and that would be something solid to take to court.

    I know Chartis is playing the standard insurance game, as they didn't even see my medical records prior to their first letter declining the payment. Not only that, why would they disregard the conclusion of medical experts who have been treating me for nearly two years?

    Anyway, enough of my self pity. Thanks for all the advice sent through PMs, I will take it all up and with any luck come out of this a happier soldier, albeit a not very mobile one :)
     
  8. The_Duke

    The_Duke LE Moderator

    ShoghunUK

    If the argument is based on differences of medical opinion, the FOS will review the medical evidence presented by both sides - yours explaining why you think your condition warrants description as being permanent and total disablement brought about by an insured event (ie an accident), and Chartis explaining why they think it doesn't (assuming that is the crux of the case). If there is any doubt about the interpretation of the wording it will ALWAYS be found in your favour by the FOS.

    For your second point, believe it or not the standard procedure for large insurers such as Chartis is not to automatically decline valid claims. They will always pay in accordance with the terms and conditions of the policy. If they didn't they would end up with real problems with the FSA and FOS. Why don't they take the word of your doctors? Almost certainly because they have had to deal with many claims where the medical statement did not match reality. I am in this industry and probably see at least a case per month where a doctor has exaggerated medical history (or even downright lied) because insurance fraud isn't seen as being fraud.

    I am not suggesting that you are attempting a fraudulent claim, but insurers see so many of them we rarely take evidence at face value. Everything is investigated. If your claim is valid, it will be paid. Valid is not just based on your medical symptoms, but also the circumstances that caused them (and how they relate to the policy wording and conditions).
     
  9. BiscuitsAB

    BiscuitsAB LE Moderator

    The_Dukes on the money and he knows his stuff. I'd add that I've seen the FOS make an award of £176000 before and even though their limit is £100k the "strongly suggested" that the firm paid the £176K.
     
  10. I might be able to offer some advise. Not sure if you are sorted out yet regarding the "Pax Shafting", any way......long story short, I was involved in an IED blast January 2009. I suffered a burst fracture to my lumber spine, which was fused and metal rods fitted to stabilise. Also bit my lip open(£500 from PAX). 18 months on and PAX/Chartis LTD are seriously taking the piss. I am still waiting for a payout for my back injury.

    1- They have said that "spinal injuries are not really on the taffiff, and fall into a grey area.
    2- They have not really been 'customer service' friendly, if you get my drift.

    Me and my wife were so annoyed with the 'I cant really be bothered act' that my wife contacted a SUN reporter. I left her to it and did not make any contact with press. The would have run a story, but there wasn't enough complaints and other 'juicy' stories took priority. Dont be afraid to stand up to these lazy knobs. They take our money, and then take the piss out of us. I will be going to the press myself if they dont pay up! Hopefully I can help you out and anyone else who wishes to make a stand against the 'Corporate menace', and give it a swift kick in the balls!!!!!.


    If you want contact numbers etc, msg me on my email address.
     
  11. BiscuitsAB

    BiscuitsAB LE Moderator

    Right I've had a look at PAX's terms and conditions and based on the info on the web site I'm prepared to stick my neck out and say that in the case of both the OP and Sharky-833 from the details of you own cases that you have given, I'd suggest that you should be looking to claim under "permanent disability" listed At section B item 15 "permanent disability not covered else where" . They will look to ameliorate the claim with the following clause in the policy conditions.

    "Conditions applying to Part One
    (Personal Accident)
    1 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. Where a bodily injury can be
    claimed under more than one item in the
    Table of Benefits, only the benefit with the
    highest sum insured will be paid.
    If the disability suffered does not relate to
    a specific disability mentioned, then we
    will assess the degree of disability suffered
    as a percentage of the whole body."

    I have no idea what their current claims experience is but I'd take a stab in the dark and guess its a hell of a lot higher this decade than any other in the last 3. There are to many variables and not enough info to say whether PAX is looking not to pay claims because its been hit hard recently or if in both cases listed in the thread the level of permanent disability is difficult to quantify.

    In the case of the OP I'm sorry to say that its fairly standard industry policy not to pay PTD (permanent total disability) claims for a period of 12 months in order to asses the permanence of the disability. Whilst it not what an individual claimant would want to hear it is necessary to protect the company and its other policy holders against spurious claims. Of course it would probably help if an individual entering into this contract understood this to be the case before they signed up, however the stop gap answer from the insurer would be "you had the terms and conditions you should have read it during your cancellation period". Unfortunately this type of General Insurance isn't as tightly regulated as some of the Financial Services Industry as its deemed to be more straight forward than other areas. In my experience this means that potential policy holders aren't given the same level of face to face advice and explanation as they may have for a different product area.

    To anyone who is going on tour and considering not having Personal Accident cover (pax or any other provider) I would say, take it out and hope its a waste of money. The area of spinal injury does seem to be slightly grey under pax's terms and conditions but I would say Section B item 15 should cover someone who has significant permanent spinal injuries not covered under the quadra/para plegia clauses.

    edited for mong spelling.
     
  12. Many companies I deal with give their final response.

    This means that this is what they want YOU to accept as final, and not to take it further this is because it may cost you time & money to do so, if you get fed up they keep all the money, if you are prepared to fight it and have a credible case they will more than likely pay up.

    They sometimes use the phrase we are only paying due to "commercial reasons" this means that it will cost then lots of time and money just to fight against you with no guarantee of winning.
     
  13. BiscuitsAB

    BiscuitsAB LE Moderator


    which is why you don't jump on the services of a solicitor right away. You can mount a very successful campaign without having to shellout to one of those leaches.
     
  14. You guys deserve better than to be fobbed off in this manner, just how many are there out there who have been left in the lurch by PAX or XPAX?! and on the other side, how many are more than satisfied with the service and with the payouts they have received? it is the nature of Accident Insurance Companies to drag claims out, we've had some real bitch fights getting deminers families paid, but given the current ongoing conflict in Afghanistan our Armed Forces need to be 100% sure of being covered.

    Myself and many others who have worked in the Mine Action/EOD field since leaving the Forces have continued with PAX in a form called XPAX, this is making me think twice about ever using them again and we need to all get a comfy feeling about them if we are to continue to use them, no doubt someone who works for them will be looking at this thread so please feel free to jump in at any moment to re-assure the hundreds of thousands who have signed up with you over the years...

    What alternative to PAX do UK Forces have nowadays? can any Senior Officers in the Forces make a study/review of Insurance in the Armed Forces?
     
  15. The_Duke

    The_Duke LE Moderator

    And companies also use "final response" to indicate that they do not wish to pursue a circular argument any further.

    Claimant "I want you to pay me my money - I am injured"
    Insurer "please provide the original medical documents for us to review"
    Claimant "No. My doctor says I am disabled, you must pay"
    Insurer "We need to see the original medical reports before we can consider your claim"
    Claimant "No. My doctor says I am disabled, you must pay"
    Insurer "We need to see the original reports before we can consider your claims"
    Claimant "No. My doctor says I am disabled, you must pay"
    Insurer "We need to see the original reports before we can consider your claims. If you are not willing to provide them, we will deem your claim invalid. If you provide them, we will continue to assess your claim. Final answer"


    Without knowing the details of Sharky_833's case no-one on here can make an honest judgement about whether the declinature is fair or not. For a PA claim to be valid there must be an insured event (in his case the IED - so OK), an injury resulting from it (in his case, the burst fracture requiring the fusing and pinning of his spine) and some form of permanent disability arising from the injury.

    This is where it gets difficult. A fused/pinned spine on its own does not constitute a disability. It is the resultant loss of function and mobility that constitutes the disability, and this is notoriously difficult to assess. It often improves over time, and hence insurers are not willing to pay out large 6 figure sums a few weeksor months after the surgery. They will wait until everything has stabilised and then have a full independant medical examination conducted to assess the disability. The longer it takes to stabilise to the point of being "beyond reasonable hope of further improvement", the longer the delay in assessing the claim.

    Bottom line - injury alone does not equal payout. Injury resulting in permanent disability in accordance with the scale of conditions shown on your policy will.