There are a number of key aspects that will make a difference between a client being paid their entitled benefit and not receiving anything at time of claim. This article looks at real life claim cases where we have successfully managed claims for clients that were previously declined or told they were unable to receive any benefit.
Claim Case 1
I received a call from a new client who was referred to me by a mutual friend. The client had recently suffered a disability to his hand/wrist and was unable to work being a painter. He was severely stressed as he had submitted the claim himself and was informed by the insurance company that his claim was declined. He was also getting behind on his vehicle lease repayments and was finding that he was starting to have to use his credit card to cover ongoing living and medical expenses. The claim was declined on the basis that the disability was a repetitive illness and the client had an accident/injury only income protection policy, hence he was not covered for any illness/sickness related symptoms. After spending time going through the policy documents/definitions and understanding the client's disability in detail, I submitted a revised claim along with a report on the client's disability and why he is entitled to a claim. This resulted in the claim being overturned and the client was paid four months of his benefit for the time he was off work including back payment from the time he initially stopped working.
Claim Case 2
Recently I was informed by one of the Poole Group accountants that their client suffered a water skiing accident and was unable to work. Naturally I suggested that the client should be entitled to an income protection benefit for the time off work. I contacted the client and explained the potential benefits he was entitled to under his policy. The client however informed me that his existing adviser said he was unable to claim and it was not worth submitting a claim form. The client also disclosed that he had two injuries in the past that were similar claims and at those times the same adviser told the client that he was unable to claim. The main reason why the existing adviser believed the client was unable to claim is that the client was receiving sick leave benefits from his employer and he did not believe that the client could also claim on his income protection policy. I researched the policy document/definitions and found that this was incorrect and that there were no offsets for the policy in regards to sick leave. Therefore I submitted a claim and within two weeks the client received over $25,000 in entitled benefits.
Claim Case 3
I was referred to a new client by one of the Poole Group accountants to review the clients existing policies. As part of the review process I discussed the clients pre-existing health issues and was informed that he was diagnosed with a malignant melanoma in 2001. On review of the clients existing policies I noticed that the income protection contract had an inbuilt ancillary benefit which pays a lump sum of six times the monthly benefit in the event of a trauma condition, e.g. cancer. I asked the client if he had ever claimed under the policy regarding his melanoma and he said no because he was never off work. He also said that the previous advisers he had consulted in the past did not mention anything about the inbuilt trauma benefit. I informed the client that the benefit is unique and that he didn't have to be off work, even though the policy is an income protection contract. Although the diagnosis was in 2001 I submitted the claim in 2010 and within one week the client received over $14,000 in benefits which was based on six times his monthly benefit in 2001. In addition to backdating the claim over 9 years I was also able to restructure the client's life insurance policy which saved him over $1,400 in tax savings and premium reductions.
Providing the appropriate initial advice and policy to meet a client's specific need is important to assist in the claims process but it is the ongoing review and claims management that is vital. As you can see with the above real life cases, having a risk specialist that understands insurance contracts, medical disabilities and most of all provides an internal claims management service will mean the difference as to whether the client receives their entitled benefit at time of claim or is told not to worry about it.
Article written by Hayden White, Adviser of Poole Group, May 2012.