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 been through the process personally but have line managed someone who has.

HR were involved in the detail, but from what I recall we basically initiated the claim with the insurer, they rejected it based on it being work related and we left it with the employee to contest this decision. I don’t think they did. Part of the description of the benefit on our system is that our HR team must deal with Al claims. It says full terms can be requested from HR. There’s nothing in the freely available information that clarifies the point about work related sickness but I assume this would be in the detailed terms. There’s a clear disclaimer that my employer is not liable if insurance doesn’t pay out.

I’ve got no idea what’s actually required of my employer and where they’re going above and beyond - but the above may be anecdotally helpful to you as an indicator of what other employers do!

But OP, you submitted the fit notes on the basis of your reasons for absence at the time. What could your employer have done about the fact that those reasons weren't going to meet the requirements of the insurer, even if they had known about this (which they might not have done)?

They couldn't have told you to change the reasons for your absence to make you eligible to claim. It isn't for them to tell you why you're off sick, and it would be fraudulent to change the records to get an insurance payout. I'm not sure what you would have had them do?

It seems that they may have been at fault if they failed to give you the SSP1 form when you had exhausted your entitlement to SSP, but even this isn't very clear.

I still don't know exactly what it is you think your employer has done wrong?

workpaysno
Op call ACAS now without further delay. They will give you advice and even tell how to reach out to the ombudsman

CALL THEM NOW AND STOP WAITING TIME & stop further delays.

ACAS -+44 300 123 1100

ok. what exactly do I ask them? I can't just tell them the whole story.

OP, call ACAS tell them everything they are there to help you and direct you. I have called them on several occasions for help and they have even with long or longer stories like the one you have. You can call them to tell* them the whole story and you will get help and directions on what to do and how to do things*

They are the policy holders. They have my fit notes. Shouldn't they know better? Are you expecting me to know about this better than them without even the policy?

No, I never said you should know better than them, but your expectations of how much they know are wildly unrealistic. The only people that can judge whether a claim can fit within an insurance policies criteria are the insurance company. I'm in HR and I've had employee claims for cancer rejected because it wasn't quite bad enough/something else in the pre-existing medical history excludes it. How on earth would I know any of that? Do you have home insurance? Can you guarantee a claim will be successful because you have a policy booklet? Of course not, because insurance companies are notorious for finding a way not to pay if they can

I'm sorry your claim was declined but your company genuinely can't do anything about it, and will not be able to answer any questions for you

OP you almost seem to think your employer should have warned you, while off on SSP, that stress wasnt going to be something the GIP would pay out for.
It would have been totally inappropriate for them to do this - you had informed them what was preventing you from being able to work so that is what they recorded - stress.
It almost sounds like if you'd known stress wasn't going to fly with the insurers you'd have picked something else 🙄
Those types of insurance policy generally only cover illnesses that don't involve self reporting of symptoms - so things like cancer or other very provable illnesses that can leave someone unable to work for a long period.
Unfortunately, for most sufferers a long covid diagnosis is based on them self reporting associated symptoms like fatigue, brain fog, digestive issues, breathlessness to a doctor who then makes diagnosis. The reason there tends to be a degree of scepticism is that technically there isn't much to stop someone reporting those symptoms even if they aren't suffering them.
Tbh considering you have been so poorly for 2 years im surprised you've had the energy/capability to go through what you have with the insurers, filing grievances etc.

HR was aware I had long covid symptoms from a very early stage and never mentioned they needed to be in the fit note at all. They just kept asking "are you back yet? your fit note has already ended" even before it had ended.
NHS takes absolute ages and long covid was not something GPs would diagnose you with, even if they could. Many GPs didn't believe in it and wouldn't even consider it in the first place.
However, I could get a letter from my GP stating something like: looking at my records, it would make sense to think that I had a covid infection from soon after going sick and have subsequently developed long covid from it, although fit notes weren't updated with it until long covid clinic diagnosed me. I was referred to the clinic within the deferred period and GPs couldn't refer you unless you had long covid for at least 12 weeks already.

I never doubted your sickness or that people can aquire conitons that last a lifetime.

But your claim was refused, that's a fact. It wasn't refused due to luck of supporting evidence it was for a condition they didn't recognise.

You could have probably appealed their decision within a time frame and lots of evidence. But I fear that you have missed your deadline for this.
That's your issue and not your employers.

Now you are saying you have long covid with a Dr note. The only real option is submitting a new claim on that basis.

So go back to your employer, ask them if they have been paying the premium for you and get another claim form.
Be prepared to fight for this one as on paper it does look like fraud.

PS:
If you really want to go down the ombudsman route, you need to
a) get hold of the insurance details. You should be able to find out what type of cover your employer took out. The terms and conditions should be accessible, but require some digging.

b) make yourself law savy! That is insurance, contract and employment.

c) find out if there are similar cases- the most difficult part - as this could be the making or braking of your case.

Then compare and see if you have a case.

Also be aware that if you do complain to the ombudsman, your case might just be filed for future reference. So if other people complain about the same thing, they might investigate further...

Sorry, but I think you're being completely unreasonable here.

It doesn't matter what HR did or didn't know. They have to accept the reasons for absence that you give for your absence when you self certify, and those that your doctor gives when they issue a fit note. It absolutely isn't their place to tell you what reasons you should give when you're off sick.

I presume that you submitted the sick notes in good faith at the time, and that your reasons for absence were stated in line with what you and your GP perceived at the time to be the truth. I don't think you can complain that HR didn't tell you to manipulate the paperwork so that you would have a better chance of claiming on the insurance policy, even if they realised this at the time.

If you believe that the GP didn't provide the correct information on your sick note, then you might have a claim against the GP (tenuous, I would have thought) but I can't see how HR has any responsibility. Did you challenge the GP at the time for what was stated on the fit note, or only retrospectively when you realised that the insurance wouldn't pay out? If you submitted it at the time without challenge, then I think that suggests that you agreed with the diagnosis at that time.

The reasons for absence that you gave at the time did not meet the insurer's requirements. That is unfortunate, but it is not your employer's fault.

Very few, vanishingly few insurers will cover long covid as it's so new the ramifications and consequences haven't been worked out yet so it's almost impossible to forcast and underwrite appropriately.

Even fewer insurers will cover stress, especially work related stress, which initially it appears that you had (long covid diagnoses notwithstanding).

Ultimately, and you won't listen but still, neither the insurer or your employer has done nothing wrong. The employer provided the insurance as part of your employment benefits and provided the forms with which you could make your claim and the insurers declined it.

Your route was to complain directly to the insurers as a beneficiary under the policy about the claim declinature. You didn't do this. You could still do this now, as you wouldn't be time barred.

After making a complaint to the insurer and receiving a response (or after 8 weeks) you can raise a complaint to the Financial Ombudsman Service. You do not need to be insurance savvy to do so, just complaint that you disagree with the decision and they will investigate.

You have no recourse against your employer, they have done nothing wrong in relation to your insurance claim (can't talk for the rest of it as I'm not informed on employment law).

I think you will not be successful in your complaint to either the insurer or the ombudsman and you should look forward to what the next steps of your employment or benefits claim should be.

Very good post. The OP would do well to take heed of this advice.

I'm sorry but you are incorrect. Income Protection covers any accident or illness that means you cannot complete your own occupation. You are thinking of critical illness which has a list of illnesses covered.

Some group income protection has a 'moratorium' clause which means that any pre-existing (or previous diagnosis thereof) could be excluded but it would depend on the insurer and specific policy.

Also typically an insurer would expect to be informed of a claim up to 6 months after the client was off work ill.

You have tried to make a claim, it’s been rejected.

The sick notes submitted were I assume a true reflection of the situation with your health at the time. Your posts are intimidating that you expect your employer to contact you and tell you to include or state other reasons for your ongoing sickness. This is unreasonable and unrealistic.

I assume you are no longer actually employed but if you are you’d probably be better spending your energy on planning some sort of return to work and any reasonable adjustments required.

Nobody is going to be paid indefinitely an income by any employer.

HR was aware I had long covid symptoms from a very early stage and never mentioned they needed to be in the fit note at all.

That is because the person responsible for determining what should be on your fit note is your GP. It is not HRs place to advise on what should be on it because it should reflect what the Medical Professional who is issuing it believes is the reason for being unfit to work

OP has your employer also refused to give you a copy of the policy document and T&Cs?

I was able to get a copy of the policy, which has many pages and each one of them seems to cover a different group of employes, from companies bought out by the employer. It just states 70% salary for max 2 years if due to illness or injury I cannot do my job full time.

Your employer does not have a duty of care to help you make a fraudulent insurance claim.

Fiddling your sick notes, as you suggest they should have advised, is FRAUDULENT.

Give it up now and go back to work.

I thought long covid wasn't generally covered by sickness insurance anyway?

I do think this is ultimately what it boils down to. The OP is aggrieved that her employer didn't tell her what to say on her sick note in order to game the system more successfully.

It doesn’t sound at all straightforward and I still think you may get more disclosure just going straight to an ombudsman claim.

It sounds like you have been a bit too quick to assume the work sickness insurance would cover everything and anything. In reality it's like all forms of insurance, there are always lots of exclusions and things like stress/mental health are often hard to evidence for a claim or excluded because they are caused by work.

From everything you've said it sounds like you don't qualify and seem to be expecting too much from your employer - you haven't worked in 2 years, why do you feel entitled to money from them?

You need to look at ESA/pip type benefits if you are too unwell to do any work at all

It does sound very much like you assumed you could have 2.5 years off work on 70% pay when you went off with work related stress. What you should have done at that time is discuss the issues causing the stress and sought a resolution, if necessary raising a grievance then and potentially negotiating an exit.

I was in a really poor mental and physical state back then, from stress and Covid. Couldn’t raise anything for a while. Employment tribunal chance gone after 3 months. How would I negotiate an exit?

I think you negotiate your exit by handing your notice in .

Negotiate an exit?

Just had your notice in like anyone else who wants/needs to leave their employer.

Situations like yours are completely exhausting, when you’re very poorly it’s an absolute nightmare, I’ve been there, you barely have the energy to do the bare essentials, it’s so bloody hard.

If you haven’t already I’d give ACAS a call for some advice. Also if you have Legal Assistance with any insurance policy you could possibly use this for legal representation. Car insurance/ home insurance? You only need to take this out with one insurer as advised by a solicitor friend.

I hope you manage to get this sorted out, you’re so vulnerable when you’re not well. Long Covid is very real, a friend has this and he struggles as much as I do and I have M.S, the cognitive function is like a fog, it’s vile. I feel your exhaustion, all the best.