Key Points


·                     It is clear a mechanism is in place that does not require medical opinion to reject a claim.


·                     Delegated authority given to an administrator


·                     Use of information not available to anyone else at the time to categorically state what no one else could possibly do - "absolute certainty of…”


·                     Twice extended the endowment policy - 4 endorsements effective 1st September 1992 and 11 more effective 1st January 1996 - all with the "pre-existing condition" clause.


…in addition to big four Heart Attack, Stroke, Cancer and Coronary Artery Bypass Graft (CABG) which do not have a "pre-existing condition" clause


·                     A silent infarction would by definition be an unknown event but would be cited as a pre-existing condition that presaged a myocardial infarction from the later medical history. Such an unknown event would fail a claim.


·                     Any congenital defect (aneurysm in artery or atrial septal defect) would also be grounds for refusal. Defects from before birth not discovered possibly till 30 or 40 years of age. These are the "impossible" claims.


·                     Parkinson's Disease. Use of Levodopa implies advanced PD. Early non-critical PD is a pre-existing condition. No successful claims for years yet.


·                     How many motor neurone disease claims?


·                     Heart Disease - Valve repair/replacement and Aorta Surgery. Minimally invasive (Port-Access) surgery does not require "opening the chest wall".


…Heart Valve Surgery is Open Heart Surgery using conventional techniques. Statistics demonstrate that only 20% will survive an aortic rupture of any kind. A purely aortic aneurysm very, very much less than this 20%.


·                              When does a Benign Brain Tumour become a terminal illness?


·                     Consultants validate the claim and provide circumstantial evidence only. GP supplies salient historical information. Once the condition has been revealed it becomes easy to assign various abnormalities to a known condition. Retrospectively.


·                     …access to the full medical history so it is easy to select alleged associated symptom(s).


·                     Confusing probability with certainty. Accepted by the Ombudsman that I could not have had any earlier knowledge…


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