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Critical illness payout for autistic child?

jenski

Hi,

I have recently discovered that I have critical illness (not terminal illness) insurance for my children and it has come to my attention that there is a case going through at the moment where a mother is fighting to claim a payout for her autistic son.  In my opinion she is more than entitled to it as autism is an incurable life long dibilitating illness and as a parent it is a life changing experience to have a child with this condition, I know that NAS are backing her.  Anyway, I am also looking into finding out about claiming on my policy and am just wondering if anyone has any experience with this?

Thanks

Parents

  • Definition of the word critical:

    http://www.thefreedictionary.com/critical

    4. Forming or having the nature of a turning point; crucial or decisive

    a. Of or relating to a medical crisis: an illness at the critical stage.
    b. Being or relating to a grave physical condition especially of a patient
     
    7. Being in or verging on a state of crisis or emergency
     
    8. Fraught with danger or risk; perilous

    http://en.wikipedia.org/wiki/Critical_illness_insurance

     

    "Critical illness insurance or critical illness cover is an insurance product, where the insurer is contracted to typically make a lump sum cash payment if the policyholder is diagnosed with one of the critical illnesses listed in the insurance policy.

    The policy may also be structured to pay out regular income and the payout may also be on the policyholder undergoing a surgical procedure, for example, having a heart bypass operation.

    The policy may require the policyholder to survive a minimum number of days (the survival period) from when the illness was first diagnosed. The survival period used varies from company to company, however, 14 days is the most typical survival period used. In the Australian market, survival periods are set between 8 – 14 days.

    The contract terms contain specific rules that define when a diagnosis of a critical illness is considered valid. It may state that the diagnosis need be made by a physician who specialises in that illness or condition, or it may name specific tests, e.g. EKG changes of a myocardial infarction, that confirm the diagnosis.

    In some markets, however, the definition of a claim for many of the diseases and conditions have become standardised, thus all insurers would use the same claims definition. The standardisation of the claims definitions may serve many purposes including increased clarity of cover for policyholders and greater comparability of policies from different life offices. For example, in the UK the Association of British Insurers (ABI) has issued a Statement of Best Practise which includes a number of standard definitions for common critical illnesses.

    Conditions covered

    The schedule of insured illnesses varies between insurance companies. In 1983, four conditions were covered by the policy, i.e. heart attack, cancer, stroke and coronary artery by-pass surgery.[2]

    Examples of other conditions that might be covered include:

    Due to the fact that the incidence of a condition may decrease over time and both the diagnosis and treatment may improve over time, the financial need to cover some illnesses deemed critical a decade ago are no longer deemed necessary today. Likewise, some of the conditions covered today may no longer be needed a decade or so in the future.

    The actual conditions covered depend on the market need for the cover, competition amongst insurers, as well as the policyholder's perceived value of the benefits offered. For these reasons conditions such as diabetes and rheumatoid arthritis, among others, may become the norm cover provided in the future."

    I think the issue here is that they are treating the claim in a blanket way.

    "Now aged four, he has autism-related digestive, bowel and respiratory conditions and a low immune system, which means he struggles with illness every four to six weeks."

    He is clearly unwell much more than would be normal, and this is co-morbid issues that he likely has because of autism, and they are referring to the autism when they should be referring to the co-morbid conditions.

    Also, they appear to treat critical illness in a survability way.  He may have very impaired quality of life, but his survivability (unless his respiratory issues are severe) are not likely to be much different than an average child.

    I think there is more going on here than would appear at first glance.  The insurers don't want to open the way to all autistic people having claims, don't forget we are 1% or more of the population.

    It may be that the parents should have claimed on a different aspect of his health than the autism itself, if that's what they did.

    I believe the NAS is right to challenge the Ombudsman, not on the basis of their decision in this individual case, but in their understanding of autism and their statement that autism improves with age.  This is very wrong.  I in fact, have regressed and I am not the only autistic person this has happened to.  (Look up "Aspie burnout").  It is akin to saying that someone with a severe heart problem who is on medication to keep it controlled has improved.  They haven't improved, external factors (i.e. medication) have kept it contained, so why should an autistic person's masking and coping skills be treated as an "improvement" in the condition?  In fact, being autistic without support, or without the right support can bring on all sorts of stress and mental health issues that negatively impact your physical health too.

Reply

  • Definition of the word critical:

    http://www.thefreedictionary.com/critical

    4. Forming or having the nature of a turning point; crucial or decisive

    a. Of or relating to a medical crisis: an illness at the critical stage.
    b. Being or relating to a grave physical condition especially of a patient
     
    7. Being in or verging on a state of crisis or emergency
     
    8. Fraught with danger or risk; perilous

    http://en.wikipedia.org/wiki/Critical_illness_insurance

     

    "Critical illness insurance or critical illness cover is an insurance product, where the insurer is contracted to typically make a lump sum cash payment if the policyholder is diagnosed with one of the critical illnesses listed in the insurance policy.

    The policy may also be structured to pay out regular income and the payout may also be on the policyholder undergoing a surgical procedure, for example, having a heart bypass operation.

    The policy may require the policyholder to survive a minimum number of days (the survival period) from when the illness was first diagnosed. The survival period used varies from company to company, however, 14 days is the most typical survival period used. In the Australian market, survival periods are set between 8 – 14 days.

    The contract terms contain specific rules that define when a diagnosis of a critical illness is considered valid. It may state that the diagnosis need be made by a physician who specialises in that illness or condition, or it may name specific tests, e.g. EKG changes of a myocardial infarction, that confirm the diagnosis.

    In some markets, however, the definition of a claim for many of the diseases and conditions have become standardised, thus all insurers would use the same claims definition. The standardisation of the claims definitions may serve many purposes including increased clarity of cover for policyholders and greater comparability of policies from different life offices. For example, in the UK the Association of British Insurers (ABI) has issued a Statement of Best Practise which includes a number of standard definitions for common critical illnesses.

    Conditions covered

    The schedule of insured illnesses varies between insurance companies. In 1983, four conditions were covered by the policy, i.e. heart attack, cancer, stroke and coronary artery by-pass surgery.[2]

    Examples of other conditions that might be covered include:

    Due to the fact that the incidence of a condition may decrease over time and both the diagnosis and treatment may improve over time, the financial need to cover some illnesses deemed critical a decade ago are no longer deemed necessary today. Likewise, some of the conditions covered today may no longer be needed a decade or so in the future.

    The actual conditions covered depend on the market need for the cover, competition amongst insurers, as well as the policyholder's perceived value of the benefits offered. For these reasons conditions such as diabetes and rheumatoid arthritis, among others, may become the norm cover provided in the future."

    I think the issue here is that they are treating the claim in a blanket way.

    "Now aged four, he has autism-related digestive, bowel and respiratory conditions and a low immune system, which means he struggles with illness every four to six weeks."

    He is clearly unwell much more than would be normal, and this is co-morbid issues that he likely has because of autism, and they are referring to the autism when they should be referring to the co-morbid conditions.

    Also, they appear to treat critical illness in a survability way.  He may have very impaired quality of life, but his survivability (unless his respiratory issues are severe) are not likely to be much different than an average child.

    I think there is more going on here than would appear at first glance.  The insurers don't want to open the way to all autistic people having claims, don't forget we are 1% or more of the population.

    It may be that the parents should have claimed on a different aspect of his health than the autism itself, if that's what they did.

    I believe the NAS is right to challenge the Ombudsman, not on the basis of their decision in this individual case, but in their understanding of autism and their statement that autism improves with age.  This is very wrong.  I in fact, have regressed and I am not the only autistic person this has happened to.  (Look up "Aspie burnout").  It is akin to saying that someone with a severe heart problem who is on medication to keep it controlled has improved.  They haven't improved, external factors (i.e. medication) have kept it contained, so why should an autistic person's masking and coping skills be treated as an "improvement" in the condition?  In fact, being autistic without support, or without the right support can bring on all sorts of stress and mental health issues that negatively impact your physical health too.

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