This post includes information
- for anyone claiming or appealing Income Protection Payments (also called Salary Protection)
- about Public Health Supports available that you may be interested in if you find yourself in financial difficulty as a result of ill health and cessation of work and income, or because of refusals of income protection payments. Public health supports mentioned include Supplementary Welfare Allowance, Illness Benefit, Invalidity Pension, Disability Allowance & there is also some information about Appeals processes.
The biggest risk to a person’s financial security is the
risk of them becoming ill or unable to work. Insurance companies offer a number
of sickness and disability policies. Income protection insurance policies are
designed to pay out in the event of prolonged ill health resulting in loss of
income. In some cases, they are part of group schemes operated by the employer
and are included in the overall employment package, a perk of the job. Other
people take out individual policies which they pay for themselves.
Income protection policies pay out up to 75% of earnings
until a claimant returns to work or reaches retirement age. Income protection
is an insurance policy that pays a replacement income on a monthly basis for a
specific period of time in the event of the policyholder being unable to work
due to illness or injury. In theory, an annual income can be insured ranging
from €10000 per annum to a maximum of 75% of your salary. When on claim, this
sum of money is paid on a monthly basis. For example, the Teachers INTO Salary
Protection Scheme is designed to provide teachers with a replacement income of
up to 75% of salary if they become ill or injured and can’t work. It helps give
financial security and peace of mind, so people can focus on getting better. Income
protection is usually set up by a broker on behalf of an insurance company or other,
e.g., Cornmarket acts as the broker for Irish Life. Most of the main insurance
companies in Ireland provide income protection cover e.g., Aviva, Zurich, Irish
Life, Royal London, New Ireland.
You can claim salary protection for when you have used up
your employer’s sick leave entitlements and passed the scheme ‘deferred period’,
that’s the time that must pass before benefit is paid. See the INTO Salary
Protection Scheme Summary Booklet as an example of a particular scheme at 1.
below if you would like to know more.
In theory, income protection pays out on all illness and
injuries. It covers stress related illnesses, any injuries that restrict the
policy holder from working e.g., knee/back injury, injuries sustained in an
accident that are not classed as a ‘serious illness’ etc. It basically pays out
any condition that your doctor will confirm in writing that you are
unfit/unable to perform their day-to-day tasks associated with your job.
In practice, from feedback, we know that people with Myalgic
Encephalomyelitis (ME), and other illnesses, find it very difficult to obtain salary
protection payments when they make a claim for the payments, and anyone awarded
payments finds it difficult to keep those payments. During the past decade or
so, there has been a steady rise in the number of claims, in particular from
people with illnesses where both the diagnosis and level of disability may be
disputed. Besides ME these concerns relate to conditions such as back pain, depression,
and stress-related disorders. As a result, some insurers are taking an
increasingly hard line, even where the diagnosis and level of disability are
not being queried by the claimant’s own doctors or the Department of Social
Protection in relation to any state benefits being paid.
The insurer’s role is to
medically assess claims and decide whether or not claims should be paid. If they
decide that a claim is payable, they will calculate and pay the benefit, but the
feedback about income protection that we have received from people with ME is horrendous,
it includes stories of use of inappropriate exclusion clauses in policies, months
and months of prevarication by high-paid customer service managers, the growing
use of ME-inappropriate functional testing assessments, e.g., CPAD, see 2. below,
and the obtaining of poorly collected evidence against claimants by the use of
private detectives and covert video surveillance. The stress created by the
insurer can cause further decline in health and drive many people with ME away leaving
them in financial difficulty and reliant on state benefits despite having paid
monthly premiums for years towards an income protection scheme.
The following is a sample of the chronology of events in the process that takes place when a person with ME submits a claim for Income Protection Payments, based on feedback from the ME community in Ireland.
The first important step in making your income protection
claim is looking closely at your policy documents to see what is hidden in
the small print on your policy in terms of how one qualifies for payments, and to check for exclusion clauses. Different
policies have varying types of exclusion clauses. Policies contain small print
which is often difficult to understand and/or open to differing
interpretations.
The next step involves completing a claim form to apply for
your income protection payments. The claimant usually has to ask their doctor
to fill a medical section on the form. The claim form is usually available from your insurer or the broker, or online via your policy or the insurers website.
Our advice is that you get your consultant, or any other specialist medic involved in your medical care, to complete their section on the claim form. From feedback we know that a consultant is the best person to do this.
The consultant and other medics you see could also write a concise letter about your illness(es) to support your claim, explaining more about the disabling nature of your symptoms associated with ME. The letter should include information about the symptoms that prevent you from working. Referring only to ME as a diagnosis may not be enough. You need to describe the disabling symptoms and severities that prevent you from working or carrying out other activities. Please see list of symptoms in the De Paul Symptom & severity questionnaire at 4. below to remind you of your symptoms, it may help you list a symptom you have but didn't think of mentioning before.
Your
doctor(s) should state that you are unwell for the foreseeable future, longer
than 12 months because of the disabling nature of symptoms and severities associated with the chronic
illness, ME. They could also refer to PEM/PENE (as per the International Consensus Criteria & Primer), see 3. below for more.
You could also include a letter/journal written by you or by your carer,
describing how you were before illness and how you are now, including the efforts
made to get better, therapies tried, medications taken, all to show that you have
made some effort to get well. There is no cure for ME and there are no universal
treatments, but some insurance companies want to see that the claimant has tried to get better, or has tried to return to work. Your doctor(s) could also highlight this in their letter supporting your claim.
Please note that in some cases, rest and pacing may not be of any benefit, the person may be confined to bed 100% of the time with severe/very severe/profound ME and even the slightest movement or a visitor to the bedroom could cause relapse. We have written before about Severe ME throughout our various pages and on our blog, and we completely understand that the person with very severe/profound ME would not be able to put in a claim for income protection or go through the various stages of a claim process, and we assume a family member, friend, carer or other would be doing this energy forfeiting and time zapping work.
Along with your completed claim form, your before and after
journal/letter, and your doctor’s letter you or the person helping you could also include some completed
questionnaires to evidence your symptoms and severities in writing. We suggest
the De Paul Symptom and Severity questionnaire as well as the De Paul PEM
questionnaire and the Bells Disability Scale. The De Paul questionnaires, based
on research into ME, are very good documents to include to provide evidence of your
illness. See links to those questionnaires below at 4. Take your time
completing them and keep copies too. Your doctor could sign those completed questionnaires to
certify them.
Please see more suggestions below for when you make a claim and advice for a potential
appeal process. For now let's go onto the next step in the process.
After the initial claim for income protection
payments is made there is an assessment of your health carried out by
a person on behalf of the insurance company, or other, who visits your home. The
insurer’s role is to medically assess claims and decide whether or not claims
should be paid. The assessor will be assessing ability and disability, watching
to see if the claimant is well enough to work, watching to see if there is
anything at all happening during the assessment that deems the patient fit for
their usual work. Anything from answering the front door to a handshake could
be deemed as capability to work. In fact, making yourself available for an
assessment can be considered as being fit for work, the process is that tricky!
Our suggestion is that because of the fluctuating nature of ME that you or your carer need to get your illness across to the assessor as if it were your worst day with ME, the day of your assessment could be one of your marginally better days and you may not get across the utterly disabling symptoms you mostly suffer. Ensure that there is somebody with you to open the front door to let the assessor in, to explain what's going on, even to speak on your behalf if possible. For some that may be the only solution because of illness severity. It is a good idea to make a list of the symptoms you have that render you unfit for any activity including your usual work and keep those to hand during the assessment, you could use the De Paul questionnaires mentioned already and at 4. below to evidence disabling symptoms and severities. When faced with an assessment it can be difficult to remember everything.
Once the claim has been made and the assessment has taken
place a decision is made about your entitlement to your claim. Claims can be
settled or declined. If your claim is declined, the
insurer will inform you of the reasons for the decision in writing. You may
appeal the decision to the Chief Medical Officer of the Insurer by sending
additional evidence supporting the fact that your claim should be accepted.
You must do this within a certain time frame depending on the insurer, e.g., 3
months of the decline decision being made. The review of their decision may
require you to attend further ‘Independent’ Medical Examinations. If you do not
appeal, it may be necessary for premiums to continue or restart in order for
you to remain a member of an income protection scheme. … difficult when you don’t
have an income of course! If your appeal with the insurer is unsuccessful, you
may bring your case to the Financial Services and Pensions Ombudsman, or use legal aid e.g., the support of a solicitor.
If your claim is settled, the insurer will arrange for a
cheque to be sent to you, or the payments will go into your bank account, this may take time.
After a successful claim ongoing assessments are typical when receiving
income protection payments. Patient feedback from the ME community
has described a situation where several people have received payments for 6 to
9 months say, and then they are called to another assessment by a so-called ‘Independent’
Medical Examiner. This assessment seems to be designed to get rid of you because
the insurance company does not want to pay out long-term especially if they suspect,
wrongly or rightly, that a person is not 100% incapacitated.
From feedback we know that one of the next assessors is also a so-called 'independent' doctor who knows nothing about ME, who doesn’t do any obvious tests appropriate to assess for any illness, whatever about ME. This assessor takes one look at the patient and deems them fit for work without any blood or other clinical testing. A few people reported that they were told that they would be well enough to return to work in a matter of months and that their payments would stop.
We have heard of people who have turned up for assessment in a wheelchair being pushed by their partner or family member or carer and despite being wheelchair bound and obviously incapacitated, they have been turned down for future income protection payments.
It can become a catch 22 situation for those severe ill to attend for reassessment, where the broker or insurer who has been told that the person receiving payments is too severe to attend for an assessment replies saying that the person will likely lose payments if they don’t attend for assessment. Our advice again is that if you are available for assessment you are seen as available for work, but there are very few alternatives it seems.
When a person who has already been receiving
income protection payments is turned down on future salary protection payments
having been reassessed they are invited to appeal the decision against
them. Following the written appeal another type of assessment can often be set
up, an assessment known as the CPAD assessment which is designed for welfare
fraud and insurance company fraud in the UK, and now used by insurers etc in
Ireland. The CPAD is an assessment that is not suitable or appropriate for people with ME
because of the activities involved in the assessment used to assess the persons
fitness to work. Again, please see more about the CPAD Assessment below at 2. if you
want to know more.
Our advice is that if you are referred to do the CPAD
assessment that you read our extensive notes about that via the link at 2. below in references.
Following a CPAD assessment, the patient usually receives a report to say that they have been turned down because they have been deemed fit to work on the basis of a few outcomes from the assessment. One can appeal the outcome of this assessment but will find themselves jumping another hoop and going for another assessment with another ‘independent’ doctor, and round and around you go til you become frustrated and stressed from jumping all the insurers hoops. The process is clearly designed to lose you.
On the back of this last assessment, the insurer will inform you in writing that you have been deemed fit for work and you will be denied future payments, giving the reasons for the decision, and suggesting that you may appeal the decision to the Ombudsman by a certain deadline.
Feedback beyond this final point has been mixed, some people walk
away because of the frustration and stress, others have no choice but to walk
away because of worsening health, some seek the help of a solicitor, others
submit their case to the Ombudsman, although current feedback suggests that the Ombudsman
has very little power in this matter.
We suggest that if you have reached this turned-down-for-payments stage that you seek
all the documents and information that the insurance company holds on you, and
more importantly that you obtain access to the various assessors’ full reports on
you via FOI or via your doctor, and go through them with a fine comb marking any
inaccuracies. You may have to access reports via your GP, signing permission
for the GP to access first (GDPR etc) then the GP will pass your file onto you, but keep
on top of the busy GP's office for those in case they forget. The insurance company are legally obliged to provide you with
all information about you and it could be useful for you to gain access to
information at any stage of your claim or appeal process. Make a note of any
medical inaccuracies or other exaggerated or misleading information about you
and you could dispute/back up with any medical reports you have or can get. Put
all into a file for use if you decide to take further action. Please note though that there may be deadlines to meet if you do decide to go futher.
You can ring the broker or insurer to ask for advice on how
to go about getting the documentation. You could also ask that the
documentation about you is sent to your doctor by registered post so that you
can track the postage and prove you haven’t received anything if your case file
doesn’t turn up. We have received feedback re missing case files, and you won't want a further delay.
Legal Advice
Some people with ME have reported to us that they used a solicitor for an income protection case and said that it makes a difference. We don't have sufficient feedback about those cases or the successful cases right now but we will update on here as soon as we know more. We are reliant on feedback from the ME community.
You might be able to get legal advice via https://www.flac.ie/ or https://www.pila.ie/ or contact the law society and ask for a pro bono solicitor to assist you. Also, there may be support from the Disability Legal Information Clinic, run by the Centre for Disability Law and Policy in NUI Galway, which provides free, accessible, confidential legal information on disability related legal issues and is available right across Ireland for disabled people, their families and supporters. In the past the clinic has dealt with issues in relation to housing, education, employment, discrimination and access to supports or services. To find out more about how the clinic works visit the website. You can also email dlic@nuigalway.ie if you have any questions or would like to arrange an appointment. See more here: Disability Legal Information Clinic - University of Galway. They may only give advice re public supports, we will update as soon as we know more.
Please note that we do not know enough about the above suggested supports and will update our information about those when we know more.
Summary of problems reported to us by people with Myalgic Encephalomyelitis (ME) who have put in a claim for income protection payments and have been through an income protection payments claim process
· Some insurance
policies/schemes contain exclusion clauses which relate to a diagnosis of a
mental health problem. Despite the fact that both ME is classified by the World
Health Organisation as a neurological disorder, and parts of the HSE accepts
this classification, we know of cases where this exclusion clause has been used
to cover ME on the basis that the insurer’s medical ‘expert’ believes that ME is
a psychiatric disorder. For what it is worth,
· When a
dispute arises and the claimant has a group policy, negotiations have to take
place via the employer. In some cases, the employer and their occupational
health department are either not interested or unhelpful.
· When a
dispute arises over eligibility, so-called 'independent' medical doctors called
in to conduct health and disability assessments often have a close and regular
financial association with the insurance industry. There appears to be a question mark
over their ability to produce truly independent reports.
· Insurers
are powerful with extremely deep pockets and there are certain types of medical
experts who are very happy to do insurance work on their behalf. These include
some doctors who are elderly and have retired from mainstream work.
· Some doctors
used by the insurers support the view that ME is a psychiatric condition and
that a form of psychological rehabilitation can cure it (this is inappropriate and potentially harmful). Such doctors tend to
support the viewpoint that many ME sufferers are malingerers and are prone to
mislead or exaggerate their symptoms (we know otherwise).
· Claimants
are increasingly being referred to CPAD assessments (see 2. below) which relates to occupational
and functional assessment. There has been an increase in the use of this by
insurance companies. The CPAD assessment is invariably operated by a physiotherapist.
The tests carried out on the person claiming income protection are highly
subjective, the assessor has been known to make some sharp observations in the
report as to the demeanour of the patient and their view of the patient’s
occupation, illness, capacity, and inclination for getting back to work.
Extraordinarily, not only is a doctor not present at the assessment, but the assessor
testing people does not usually see medical records or reports about the
patient. A common complaint is that many people are asked to complete a number
of work and daily living tasks over a very short period of time during a 2-day
assessment. If they are able to perform the tasks to a reasonably satisfactory
level, they may then be declared fit for work, even though they would be unable
to perform at this level for a whole day or sustain this activity on a regular
day-to-day basis.
· Insurers
make use of undercover surveillance involving private detectives and video
recordings. Many people with ME are not confined to the house and may well be
outside doing some gentle activity or driving their car to the shops, doctors’
appointments, etc, but the fact that they are ‘caught on camera’ performing a
physical activity may then be used as ‘evidence’ that they are fit to return to
work. It is a fairly cynical attempt to harass claimants after agreeing to pay
or resume payments to them. It has been known to cause immense distress to the claimant.
· Some
people with ME are being coerced into doing therapies such as Cognitive
Behavioural Therapy (CBT) or Graded Exercise Therapy (GET), we know that there
are other names being used for exercise therapies since NICE guidelines 2021 stated
that graded activities should not be used by those with ME, do not be fooled
into doing any activities which could be harmful to you. See point 5. below for
more on the dangers of GET and useful resources you can include to inform about
the dangers of GET
· Refusal
by the income protection insurer to accept that Dept. of Social Protection
decisions regarding disability assessments is not uncommon, someone may be in
receipt of both Illness Benefit, then Disability Allowance or Invalidity
Pension, but the insurer does not accept that they are ill enough to meet their
policy criteria.
· The
tactics used by many of the insurance companies are similar, they are getting
more hostile to claimants generally and ME sufferers in particular. There
exists a climate of fear and hostility between insurer and claimant.
 |
| From The Sunday Times Oct 25th 2020 |
Summary
of advice and information when making your initial claim
and/or an appeal
-
Get a strong letter of support from your GP and
your consultant(s) and/or occupational therapist to confirm that you will be
incapable of work for an indefinite length of time, i.e., longer than 12
months, because of the chronic disabling nature of ME.
-
Include copies of completed and certified
documents like the De Paul Symptom & Severity and PEM questionnaires, and
the Bells Disability Scale, see 4. below
-
You gather up all recent MRI, CT and x-ray
reports no matter how relevant they are. Add every single report from all
consultants/specialists and bind them in a folder. Write a letter with it too
with a description of your symptoms, what the outcome was from the scan/report
and annex it. For Example, Annex A - first CT scan and date. Add any report
associated with your scan. Annex B- Brain MRI and the report, and so on
depending on medical records you may have. Include everything, no matter how
small you might think its relevance.
-
You could add a list of all the prescription
meds and all the supplements you are taking.
-
You could include a brief ‘before and after
illness journal describing how you were before illness, i.e.,
work/hobbies/activities/health, and how you are now with chronic illness,
giving an account of your worse day and the disabling symptoms. Remember some
people with Myalgic Encephalomyelitis (ME) can experience fluctuating illness,
seeing a relatively moderate day, and then following activity seeing horrendous
days, don’t forget your worse days when getting across how debilitating and
disabling ME is, i.e., the debilitating symptoms and features of your ME that
prevents you from doing an activity and deems you unfit for work.
-
You could add detail re the various
treatments/therapies you have tried over the past months/years (which could be
considerable). That way you are providing evidence of your attempts to get
better and ambition to return to work, as well as showing how ill you are.
-
You could add a letter from your GP pointing
out that because of your symptoms you are unable to work...this can work better
than ‘because of her ME she can’t work’ because insurers don’t recognise ME but
may recognise and consider the list of debilitating symptoms that prevent you
from working in any job or being active in any way.
-
You would do best to include a consultant’s
letter outlining diagnosis and inability to work indefinitely, and an explanation
of why you are unable to work, i.e., you have disabling symptoms that prevent
you from being active, and because of the cardinal feature of ME, i.e., PEM. If you don’t see a specialist then the GP
needs to make a stronger case that ME is relentless and specifically to say that
there’s no cure and that it is imperative that you avoid PEM. The main line is
that the illness is chronic, and patients suffer for decades. No one can decide
when you are better.
-
Some consultants can say things in a letter
like ‘has improved’ on such and such a drug or therapy and that definitely does
not help so leave anything like that out of the documentation you include
as part of a claim or appeal. The bottom line is that with ME we see ourselves
having ‘good’ days and bad days. You need to describe your absolute worst day
because though we have ‘good’ days we know the bad days come and that’s only
what they need to hear about. Don’t include any positives whatsoever. Give a
very clear and concise outline of your typical worst day and your struggles
with regards to activity, mobility etc.
-
Remember that when you are refused payments it
is not personal, it’s the system trying to put people off and not pay them. You
are just a statistic.
-
Some people have won the battle against
insurance companies and continue to receive payments. The assessments continue and
there are other hoops to jump, and it appears to be an ongoing situation. Some people
have had therapies suggested to them and insurers have said that they must complete
the therapies in order to keep their payments, this is completely wrong and
potentially harmful to someone with ME, please see the information at 4. Below re
Graded Exercise Therapy (GET) if you have been advised to do any kind of exercise
therapy which may have a different name. Your doctor could write a letter on
your behalf to explain the dangers of any kind of graded activity.
- There are so many brick walls that some people have resorted to hiring a solicitor to pursue a case against insurers and there have been a few successful outcomes.
References & further information
1.Cornmarket's INTO Salary Protection Scheme Summary Booklet:
2. CPAD Assessment: https://meadvocatesireland.blogspot.com/search/label/CPAD%20Assessment%20%26%20Advice%20re%20CPAD
3. PEM/PENE (as per the International Consensus Criteris): See sections on PENE and more on the importance of rest and pacing in the post via this link ME Advocates Ireland (MEAI): Managing & Treating Myalgic Encephalomyelitis (ME) Day 11 ME Awareness Month
And more on PEM/PENE in the International Consensus Primer on page 2 Microsoft Word - 2012-Nov25 - Myalgic Encephalomyelitis International Consensus Primer (Autosaved) (investinme.org)
4. De Paul Questionnaires:
Symptom & Severity Questionnaire: https://www.researchgate.net/publication/358282115_DePaul_Symptom_Questionnaire_2_DSQ-2
PEM Questionnaire: https://www.researchgate.net/publication/358282034_The_DePaul_Post-Exertional_Malaise_Questionnaire_DPEMQ
Bells Disability Scale: https://meadvocatesireland.blogspot.com/search/label/Bells%20Disability%20%26%20Severity%20Scale
More information on the above
questionnaires in this post here: https://meadvocatesireland.blogspot.com/search/label/Diagnosis%20of%20Myalgic%20Encephalomyelitis%20%28ME%29%20Part%201.%20%20%20-%20Tools%20for%20Diagnosis
5. Information including warnings re Graded exercise Therapy (GET): https://meadvocatesireland.blogspot.com/search/label/GET%20Must%20Be%20Avoided%20if%20You%20Have%20Myalgic%20Encephalomyelitis%20%28ME%29
There are public health supports available that you may be interested in if you find yourself in financial difficulty as a result of ill health and cessation of work and income, or because of refusals of income protection payments. It takes great patience and time to deal with the Irish application processes which are slow and arduous at the best of times but there are a variety of supports to apply for. One such support is Supplementary Welfare Allowance.
Supplementary Welfare Allowance (SWA) is a means tested payment. In a means test the Department of Social Protection examines all your sources of income. To get SWA, your income must be below a certain amount. You can contact your local community welfare officer to receive that ‘emergency money’ while you are waiting for the outcome of an application and/or appeal.
Local Community Welfare Services can be contacted through your local Intreo Centre or Branch Office. See list of those here to find your local centre here.
Please see useful information on our blog about other welfare and public supports via the two links below:
Social Welfare Payments:
ME Advocates Ireland (MEAI): Social Welfare Payments
 |
Public & Community Health Supports Ireland:
ME Advocates Ireland (MEAI): Public & Community Health Supports Ireland
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