Sick Pay

[Meli96]

I’m in London. UK. I’ve been off sick for nearly 2 years. First 12 months fit note said stress at work, but changed to Post Covid syndrome (long Covid) Anxiety and depression thereafter. I have income protection as employee benefit but he didn’t help and it was declined (even the appeal). Tried raising grievance but HR declined to even discuss it. What options do I have for income whilst sick?
Sick note resets after 12 months but I haven’t worked in between the sick notes when reasons for illness changed.
Cant find help to prepare for ombudsman or even fight insurer, which my employer should be doing.
any ideas or suggestions appreciated

I’ve never gone to ombudsman before and I do certainly need help with that.

So, I gather that you were off with work related stress and the insurance company declined your claim.

What is their criteria in terms of paperwork you need to supply? Dr or Occupational health reports, seeing an appointed health professional, evidence of treatment, ... ?

I think something went wrong or was missed for your original claim.

The big question now is, if you are still able to claim, or if you are outside their set time frame for claiming anything.

Income protection comes from an insurance company, I don’t believe that comes from your employer. It’s a separate thing entirely.

I agree with this.

if you are wanting to appeal the claim with income protection, you need to find out what their criteria is.

unfortunately, they may be right, in that, stress isn’t a diagnosable condition therefore it may be excluded, but really, this needs to be clarified and I’d be inclined to find this in writing…

I hope you are ok, and that your health is improving. I've read all your responses and have faith that the correct outcome will be applied.
As a small business owner, if an employee was off sick for two years I wouldn't have much patience left, would likely be out of pocket already having to find alternative staff to do your job, so unfortunately wouldn't be much support any more.

Sickness policy is 70% salary for 6 months (including SSP in it). After 6 months you should get GIP (Group Income Protection), employee benefit & paid solely by employer. GIP is 70% salary for 2 years

This is an insurance policy which your employer has to claim on and is up to the insurer whether they pay out. There is usually a list of conditions they cover, it's not every illness. HR should have given you forms to fill in and submitted them for you.
As mentioned by other posters you could appeal the decision by the insurer.

Do you have legal cover included on your house insurance. Or are you in a union? You need a solicitor to advise I think.
You could also try calling ACAS for advice.
You could also request a referral to occupational health to look at reasonable adjustments to help you return to work. Some of the long covid groups may be able to advise what types of reasonable adjustments others have had. Phased return/work from home/covid mitigations for in person work may be examples of possibilities.
Good luck and I hope you find improvements soon

The employer pays for it, so they are the policy holders. Employees are the beneficiaries. The insurer would pay employer and employers pays you. It’s an employee benefit.
people may also pay for it themselves but not the case here.

Already appealed directly (employer didn’t help), and declined. Employer doesn’t want to know and behaves like they don’t know anything

On what basis was the original claim and the appeal declined?

What makes you think they were wrong?

I submitted them directly and had to ask insurer for help with the forms. Employer didn’t help besides emailing forms. Also had to do SAR to have declined reasons in writing and had to appeal directly too. No help from employer besides providing forms. They provided their claim and copy of job description I had never seen before.

OK, so what were the declined reasons and why do you think they are wrong?

I've claimed on a work health insurance policy. I wouldn't expect employer to help me with the forms. I think you're too focused on that and not enough on the actual claim.

Stress is symptom and not illness. All evidence provided is letters from doctors and OH who just believe what I say. No independent evidence (but they maintain the CPAD done by a company they pay for and their report that is not shared with me even with SAR, it’s the only “independent evidence”).

Only the policy holder (employer) can sue for breach of contract. It takes a long time to get diagnosed with long covid. Hard to get GPs to even refer you to long Covid clinic, then wait a few months to be seen by them.

Your expectations of your employer sound very unrealistic. I don't see why it's their duty to assist you with an insurance claim simply because they offer you this insurance as a perk of your employment. It is your responsibility to make the claim and to submit any appeals etc.

I'm amazed that your employers haven't already dismissed you on the grounds of capability. You say that your line manager doesn't contact you except to say get well soon in response to your sick notes, but what sort of contact are you actually expecting? After 2 years, it doesn't seem likely that you're ever going back so the only likely contact at this point would surely be to initiate dismissal proceedings on the grounds of capability, I'd have thought.

If you don’t have the policy, you don’t know small print, conditions, etc.

Your expectations of your employer sound very unrealistic. I don't see why it's their duty to assist you with an insurance claim simply because they offer you this insurance as a perk of your employment. It is your responsibility to make the claim and to submit any appeals etc
This

My company provides insurance but any claims etc are to be sorted directly between employees and insurance company. It was like that everywhere I worked.

Regarding the Income Protection, OP have you asked the insurer for your cover T&Cs? Even if it was contracted by your company, as beneficiary you should have access to it.

I suspect that they only cover people not being able to work due to medical conditions that can be tested, cancer, back surgery, this type of things. The issue with stress / long covid is that there is no clear line between suffering from it or not, and how much it prevents you to work. There is nothing that can be proven.

Each company is different, even within the same industry. Just because that’s what you’ve seen, doesn’t mean they all do.

The insurer wouldn’t even tell me the deferred period because I’m not the policy holder. So no, no info from them at all. Even when I did the SAR, still no policy, Ts&Cs at all. If so clear, why wouldn’t they share the CPAD report with me? Which they agreed to before it was done. If so transparent and professional, why not sharing it? Just making it harder and harder for people. When was last time you heard of an insurance company approving a claim?

I signed auth for OH during appeal, but employer didn’t refer me and ignored my emails chasing them, until nearly 4 months later, when I raised a grievance about something else completely unrelated. It felt like retaliation, if you ask me.

I raised the grievance and they replied it was nothing to do with them and go to ombudsman and refused to have the meeting for the grievance, as if it wasn’t applicable to the situation

That sounds perfectly reasonable to me. The insurance company/ombudsman decisions are nothing to do with them, so what would be the point in them hearing the grievance. Just a waste of their time and yours.

If your grievance was about how they handled the OH referral, then they should have heard that. But given that they told you to go to the ombudsman, it sounds like that wasn't how the grievance was presented to them.

Your OP: Cant find help to prepare for ombudsman or even fight insurer, which my employer should be doing.

In this case not having the policy in advance didn’t make any difference. You were signed off with stress and stress isn’t covered.

Unless you were planning a fraudulent claim (choosing a covered condition to be signed off with) it makes no difference.

The claim has been declined because they don’t cover stress. This was upheld at appeal.

Now you are signed off with long covid, you need to submit this as a new claim.

Last year, weeks off with operation, the insurance co paid what they had to.

Can you set out a timeline with what you did and when.

Your posts are jumbled, you are replying to yourself and I'm not sure what you want help with.