# Living Cover Life Insurance Claim Denied



## atmurphy (4 Apr 2008)

Hi folks,
           been a while since I had a question for this form but recently my wife had an accident in which she broke her neck. Thankfully, she is ok and well on the road to recovery. My question is around the Living cover we have on our Life Insurance. Under the terms & conditions of our policy we entitled to a % of our living cover due to the injuries suffered by my wife. The insurance company have returned our claim saying that because my wife signed a waiver with regard to an ongoing back injury she had at the time we took out the policy she is not entitled to make any claim. My questions are as follows:

1. Is the Neck considered part of the back. Is this just an insurance thing 
    or a medical thing ? 

2. As the waiver states nothing about broken bones, the spinal cord/canal
   do we still have a valid claim?

We have a meeting with her consultant next week but any info in the mean time would be greatly appreciated.


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## Ravima (4 Apr 2008)

Get copies of everything you signed and study them in detail. You will need to see exactly what your wife signed away.

I would think that neck is part of back/spine, but am open to correction.


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## LDFerguson (4 Apr 2008)

Sounds like there was an exclusion on the original policy.  If it's not too long, why don't you copy the wording of the exclusion here?


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## atmurphy (5 Apr 2008)

LDFerguson, 
                  The wording of the exclusion is as follows:
This policy shall exclude any surgical operation, investigation, or hospitalisation arising directly or indirectly to the back, it's intervertebral discs, nerve roots or supporting musculature and ligaments. Total Permanent Disability and partial Disability also excludes the back.

So again, there is no mention of the Spinal cord or canal which she had bone fragments removed from and 2 vertebra pinned. The section of the policy we are claiming on requires surgery to the spinal cord or canal. As this is not mentioned in the exclusion I believe she still has a valid claim.


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## mercman (5 Apr 2008)

Surely the injury was caused by an accident at a different time, different place and in another part of the OPs wife's back. Therefore if you can prove that the old injury had no part to play with the accident and the broken neck was a direct cause of the latest accident which the class of the injury was not compromised or accelerated by the fact there was a previous injury your claim against the Insurance Co. remains valid.


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## atmurphy (5 Apr 2008)

Mercman,
              I agree, my wife's original back problem was in her lower back & a muscular issue and was back in 2000. When setting up our policy, she declared that she had been off work once with back pain (she works as a nurse) and required some medication and rest. Think she was off work for about 2 weeks. The injury (broken neck) she suffered back in January bears no relation to the original, and as it was a fall from a horse, wasn't a reoccurrence of the old injury. I am currently in the process of wording a very strong reply and any help would be much appreciated.


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## mercman (5 Apr 2008)

This is a very serious accident which requires a very serious letter from a very serious solicitor. How can the Insurance industry class themselves as ethical in an instance like this - they take the premiums but will wiggle out of any claim no matter how obvious it is. Go for it.


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## LDFerguson (6 Apr 2008)

I'm going to look at this from both sides...

I think most medical definitions of the back and it's supporting musculature and ligaments would include the spinal cord.  So by the strict definition, the insurance company are probably correct to refuse the claim.  

I'm not a medical practitioner, so you should discuss this point with your wife's attending doctor.  

Having worked many moons ago in an insurance company I do recall a line in thinking that went along the lines that your wife's previous injury may have weakened her spinal cord, with the effect that her injuries may have been more severe in the accident than they would have otherwise been.  This may or may not apply in this case.  

Having said that, I think a challenge to the decision is worth the effort.  Rather than just writing yourself, you should get the consultant who looked after your wife's recent injuries to state in writing that her injuries in the accident had no connection whatsoever with her previous back complaint.  Send that to the insurance company and ask them to review their decision to reject the claim.


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## LDFerguson (6 Apr 2008)

mercman said:


> How can the Insurance industry class themselves as ethical in an instance like this - they take the premiums but will wiggle out of any claim no matter how obvious it is.


 
From what I can tell, atmurphy's wife has had her claim rejected by one insurance company.  How do you jump from there to saying that the entire insurance industry is to blame for this?


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## mercman (16 May 2008)

At last, the Insurance industry has recognised their mistake. What a pity that one must go through all the aggravation for a claim to be processed.


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## LDFerguson (16 May 2008)

mercman said:


> At last, the Insurance industry has recognised their mistake. What a pity that one must go through all the aggravation for a claim to be processed.


 
Eh?  Did I miss some post in the meantime?


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## ClubMan (16 May 2008)

Yes - a post from the thread starter in breach of the posting guidelines was deleted.


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## atmurphy (17 May 2008)

Just a quick update. Sent the Insurance company in question a very strong worded letter. They called this morning to say that they had made a mistake i.e The back & neck are not one in the same when it comes to the medical definition of the human body, and would be processing our claim ASAP. Seems Mercman you have a point. Looks like they just wanted to wiggle their way out of the claim. Cheeses me off no end and I told them as much this morning. I asked how many other people they try it on with on a daily basis. Told them I will be lodging a complaint with the Financial Services Ombudsman.


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