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How to make a claim

Despite increasing payment rates, there are still steps that advisers can take to help the claim process run more smoothly. Rhys Dudding, underwriting and claims development manager at Zurich UK Life, takes a look at the critical-illness and death claim process

Notifying a critical-illness and death claim

Customers can notify their insurer of their need to claim by telephone, in writing or by email. Notification can come from the customer themselves, their financial adviser, a family member, personal representative or trustees.

At this time, the insurer will conduct identity and verification checks. The insurer must be certain they are dealing with the correct customer, that the policy remains in force and the correct contact details are on file.

For critical-illness claims, the company will also check that the customer is claiming for a condition that is covered by their policy.

If it is clear that the condition they are suffering from is not covered by their policy, the insurer will notify the customer.

Issuing the claim form and detailing requirements

On receipt of notification, a claim form will be issued with a covering letter detailing information needed to progress the claim including:

  • Medical reports to confirm the customer has suffered a covered condition or undergone one of the operations covered under their policy
  • Original death certificate
  • Original grant of probate (if appropriate)
  • Letters of administration (if appropriate)

The company will also check for non-disclosure about material facts regarding their health and activities.

The importance of accurate disclosure

Deliberate non-disclosure by a customer will result in a claim being declined and policy terminated.

To avoid this, it is critical that sufficient and appropriate questions are asked before a policy is issued. They must be answered correctly and responses fully recorded. Even if medical evidence is subsequently requested, the customer still has a duty to provide accurate information.

The Association of British Insurers’ guidance on application form design for life and health protection insurances, published in 2006, made two key recommendations -the avoidance of “memory test” questions and the avoidance of combining unrelated illnesses within the same question.

The guidance did not extend to specifying which illnesses or risks would be asked about because it is a matter for the insurer to determine what is relevant to the assessment of risk. Questions asked will vary from one provider to another.

Problems often occur when a customer is uncertain about which aspects of their medical history to include. Honesty is always the best policy.

The critical-illness claim process

The following process will apply:

The claim assessor will check that the customer is claiming for a condition covered by their policy. The claim team will then request the relevant medical evidence and any other information needed to assess the claim.

A medical report from the customer’s GP is required. The GP should have all relevant correspondence on the customer’s personal medical records. Consultant specialist reports are also requested where the customer has been treated in hospital but the GP may not yet be in receipt of the full details.

Once the evidence has been received, which usually takes up to five weeks, it will be assessed to ensure the validity of the claim and for non-disclosure and once a decision is made, the customer is notified with valid claims paid within a few days. If further evidence is required, the process continues with the customer being kept informed of progress. On average, the whole process takes six to eight weeks.

In 2008, the average acceptance rate for critical- illness claims across the industry rose to 88.6 per cent from 85.5 per cent in 2007; death claims paid also increased over the same period from 98.4 per cent to 99.1 per cent.

These improvements can be directly attributed to the process improvements that the industry implemented during 2008.

Death claims

For death claims, the following process will apply:

Once the claim form is received and assessed, the original death certificate will be required identifying the customer, their marital status and the cause of death.

Without the death certificate, the claim team will not know what additional evidence they will need to be able to make a decision on the claim. The claim team could ask for medical or coroner’s reports to check validity and, as above, for non-disclosure.

The claim team will also need to eliminate suspicious circumstances surrounding the cause of death such as murder of the policyholder or fake suicide.

If grant of probate has been requested by the company, this must be sent. In some instances, such as joint-life first-death, claims will not need a grant of probate because the proceeds are paid to the surviving partner and do not form part of the estate.

Once all the evidence has been received and assessed, a decision will be made and the executors or the trustees will be notified with payment of the claim made within a few days.

Death certificate

Without the original documentation, the company will not be able to authorise the payment of the claim.

Upon death, assets of the deceased will form their estate. This is distributed according to their will or according to laws of intestacy if there is no will.
Prior to the estate being distributed, the person responsible for administering will have to apply for a grant of probate, depending on the size of the estate. Secondly, any inheritance tax will have to be paid, often before probate allows funds to be released.

Grant of probate

Probate is the legal procedure by which a will is authenticated and confirms the authority of the executors to administer its contents. The grant of probate is a certificate that validates the will and authorises the executors to administer the estate. Letters of administration are the equivalent to probate for individuals who die without a will (dying intestate).

The insurer will advise the customer if a grant is one of the requirements needed for the claim. In these cases, the executors must apply for a grant. It is then necessary to obtain all the information about the estate, which can take up to six months or more. There is a small cost associated plus legal fees and the executors will have to swear an oath.

Trusts

Any asset that is written in trust will either be paid to the beneficiaries directly, if that is the instruction of the trustees, or via the trustees without having to obtain the grant of probate as the asset does not form part of the estate.
This means the proceeds of the trust will be available quickly to meet any outstanding inheritance tax liabilities. Trustees will need to have a bank account in place for the insurer to make payment.

Tips to speed up payment

  • Ensure there is an appropriate bank account set up for payment to trustees
  • Check the insurer has the most current details for the customer, executor and trustee
  • Help the insurer to chase any outstanding medical reports
  • Share any additional information with the insurer regarding cause of death, especially if an inquest is to be held.

If the adviser follows these tips, they can help make the claim process as smooth as possible, ensuring a good experience for the customer, with valid claims being paid quickly by the insurer.

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Comments

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  1. I made a illness claim via Zurich insurance, as i became ill for life, the illness is not listed under the “normal” terms that is because its a rare condision, but the form was filled in and i have been wiating and chasing the claim now for over 2 years!!
    I am the person that gets the info, then chases the info for the insurance company, and i am the person that has to keeps calling them about the claim, i feel very let down by them, and i have to do this while all the time thinking that this could be my last day of life, and what will happen to my family if that happends! i would like to be able to enjoy the time i have left now not when i am gone!
    I would never tell anyone to take out insurance with Zurich!

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