Incapacity insurance claim denied due to lack of objective proof of chronic pain
February 2, 2011 10:30 AM   Subscribe

About to have an incapacity insurance claim denied due to lack of objective proof of chronic pain in the UK. What are our options?

My SO has had ongoing chronic pain type problems for around 5 years, and has seen many many specialists but does not have a specific diagnosis. She was working up until about 6 months ago, and has incapacity insurance with her employer through Friends Provident. She has been unable to work for the past 6 months, and has made a claim, but FP tell us that they are about to deny it on the grounds that there is no "objective clinical evidence" that she cannot work.

There doesn't seem to be a good prospect of getting any "objective clinical evidence" because of the subjective nature of her problems (mostly pain, some muscular issues, some depression / anxiety). All tests she's had (vitamin levels, x-rays, MRI scans etc.) have come back normal. All the doctors do seem to accept that she does have real problems, but none of them can suggest any causes or treatments other than symptom management (CBT, massage, anti-depressants etc.).

Does anyone have any advice for how to deal with this? Is there any kind of objective test we can have done which might give us some evidence?

I have found a few lawyer pages suggesting that an "objective evidence" test in pain cases is unfair and can be challenged in court in the US [1] and Canada [2].

Does anyone know whether the law is the same in the UK? Does anyone have any similar links or references to relevant case law in the UK which I can show to the insurance company? Would that be wise?

Thanks in advance.


posted by richb to Work & Money (4 answers total)
Is pain management a specialty in the UK? A PM doc might know how to get "objective clinical evidence." They also might be a better specialist for her anyway.

Also, FWIW, MRI's are useful but sometimes they miss important clues. For example, I know someone who had a back fusion, after which he had terrible pain. They thought his cage had shifted or was causing him problems somehow, but the MRI's all looked normal. Eventually they went in to take the cage out anyway, and discovered a huge nasty bone spur around one of the screws, putting pressure on the spinal cord; somehow this didn't show on the MRI. I know how terrible it is to live with chronic pain and no idea why it's so bad; it's even worse when you've had all the tests and they still don't know. It might be helpful to realize that the tests don't always show *everything*. Good luck.
posted by galadriel at 12:06 PM on February 2, 2011

Although I've lived in the UK since 1997, I've never (thank the Good Lord!) had reason to engage an insurance company but I have had many, many complaints against retail banks escalated to the Financial Ombudsman.

The US / UK legal systems are just as different as the languages; sometime these differences are subtle othertimes pronounced. For example, in the United States litigation is undertaken far, far earlier than here in the UK. More than likely your friend will have to deal with insurance companies internal complaints resolution service before the Ombudsman will get involved.

Only after you've exhausted the insurance companies complaints process - effectively giving them a chance to resolve the complaint can you approach the Ombudsman, who will engage in a fact finding then resolution process. Typically (in the case of banks, for example) the internal process will consist of three phases, each engaging a more senior level of the firms staff.

The entire process could easily take several months and typically (although I'm not sure in this case) litigation couldn't be undertaken until both the insurance company as well as the Ombudsman were engaged.

Also keep in mind that "no win / no fee" arrangements (off the pages you've linked to) are handled differently here in the UK and, even if allowed (this isn't always the case) its entirely possible that if your friend loses she would be liable for the opposing parties costs (e.g., legal and court fees).

So I seriously doubt the laws are the same and even if they were the way the case would be conducted overall would be somewhat different.

Regardless, first stop is the insurance company's internal complaints, then the Ombudsman. If your friend strikes out with both parties the final communication from the Ombudsman will contain helpful instructions of further rights including litigation (I've been at that point several times).

Oh yeh, another difference: many folks access the legal system via Citizens Advice; it might not hurt for her to contact them early on, if for other other reason than to insure she's fully informed of her rights.
posted by Mutant at 12:16 PM on February 2, 2011

Response by poster: @galadriel - Thanks. We haven't seen anyone who describes themselves as a "pain" specialist, and I'm not sure there is such a thing in the UK. She is awaiting admission to an inpatient course for unexplained chronic pain & similar conditions, but it's a few weeks away. As far as I can establish, there is no objective test which can demonstrate the presence or absence of pain.

@Mutant - Thanks. I understand that litigation isn't an option yet (we haven't even gone to the insurer's internal appeal process yet). I was thinking that some case law references from the UK might be helpful just to preemptively knock down this "objective evidence" test they are insisting on and which we can't possibly satisfy. I don't have access to any legal search engines, and I was hoping that someone might be able to give me some supporting evidence.

We've been to Citizens Advice in the past for related matters, and they're terribly over subscribed in our area (if not everywhere). You have to queue all morning on a weekday, which is very hard for my SO (due to her pain, obv), and not very practical for me, as I work full time.
posted by richb at 2:04 AM on February 3, 2011

I got a few hits when I googled "pain management" NHS, like this one:
which mentioned pain clinics. Perhaps that's what she's waiting on now, but if not, it looks like it is certainly there.

I'd never heard of pain management until the first time I was referred to a pain management clinic, which incidentally was about 5 years *after* I started having incapacitating pain. It seems like something they'd think of first, but apparently not. Maybe her docs need a nudge.

There may not be any standard objective tests, but someone who deals with pain full time, and only pain, may have some insights into proving incapacity from pain.
posted by galadriel at 9:16 AM on February 3, 2011

« Older comparing sentence structures to death   |   SFX in the US Newer »
This thread is closed to new comments.