Policy

The claims process

To make a life insurance claim, you will need:

  • A completed claim form;
  • Details about the condition including diagnosis and doctors’ appointments;
  • Copies of any medical certificates, reports or tests; and
  • For a claim in the event of someone’s death, you will need a copy of the death certificate.

Who do I speak to about my claim?

If you bought your insurance direct from an insurer

Call the insurer as soon as possible to let them know you need to make a claim

If you bought your insurance through a financial adviser or planner

Call the adviser or contact the insurer directly.  The adviser can assist you to put your claim together

If you hold insurance through superannuation

Speak to the super trustee in the first instance who can give you more information.  The trustee can provide your claim information to the insurer on your behalf

If you hold insurance through an employment arrangement

Speak to your employer in the first instance who can put you in touch with the insurer

How you can assist with your claim

Making a claim on a life insurance policy can be time consuming if the appropriate steps are not taken.  Consider the following:

Check the policy documentation:  Life insurance policies and procedures can vary between insurers, so before you do anything else, check your policy documents carefully.  This is to make sure that you are aware of the process and that you have all of the relevant information that the provider is likely to ask for on hand.

Make contact as soon as possible:  It is critical that you begin the claim process as soon as possible, so that you can get any early support you may need.

Be organised and get all of the required documents and assessments as soon as you can:  The insurer will require different types of documentation and may also require you to attend independent medical assessments.  It is essential to be organised during this process so that you do not experience delays in receiving your benefits.

When you make a claim 

The following information is contained in the Life Insurance Code of Practice. Insurers must be compliant with these standards by 1 July 2017.

 

 

Within ten business days of being notified about your claim, your insurer will provide an explanation of your cover and the claim process, including why certain information is requested and any waiting period before payments will be made.

Your insurer will tell you what information you need to provide and what assessments you need so that a decision can be made on your claim.

 

 


While your insurer is making a decision on your claim, they will be in touch with you to give you an update at least every 20 business days.

 

 


Once the insurer has the requested information and has completed its enquiries, you will be told the decision on your claim within ten business days.

If you are unhappy with any aspect of your claim process, you can make a complaint to your insurer. 

Insurers are there to pay legitimate claims - more than $7.8 billion is accepted and paid in claims each year.

Urgent financial need

If you are in urgent financial need of your life insurance benefits while your claim is being assessed, you can speak to your insurer about:

  • prioritising the assessment and decision in relation to your claim; and/or
  • making an advance payment to assist in alleviating your immediate hardship.

You will need to demonstrate your urgent financial need with documentation, such as:

  • for Centrelink clients, your Centrelink statements; or
  • financial documents including bank statements.

You will be told the insurer’s decision within five business days of receiving your documentation.

Income Protection claims

Notify your insurer, adviser or super trustee as soon as possible so that they can work with you and your doctors and employer to help you to recover and support you to get back to work where possible.

Income protection claims usually have a waiting period before benefit payments are made. 

 

 

 

For the majority of claims, a decision will be made no later than two months after notification, or two months after the end of the waiting period (whichever is later). 

 

 

In a small number of claims where there are unexpected circumstances,such as delays in receiving specialist reports,a decision will be made no later than 12 months after the insurer is notified of your claim.

Income protection claims usuallyprovide regular payments rather than the one-off lump sum payment that other types of life insurance pay. If your insurer offers to pay you a lump sum instead of ongoing payments in order to finalise your claim, you may wish to seek financial and legal advice before accepting the offer.

If you are receiving regular payments for an income protection claim:

  • You will need to provide information on an ongoing basis so that the insurer can make sure you are still entitled to benefits or to calculate your payments. This can include reviewing your medical condition or symptoms, your capacity to work, and your financial circumstances.
  • If your payment is going to be delayed, for example because you have not provided some necessary information, your insurer will get in touch with you beforehand to let you know the reason for the delay so that you have an opportunity to remedy this.

All other life insurance claims

If your claim is for total and permanent disability, there is usually a waiting period before benefit payments are made. 

 

 

For the majority of claims, a decision will be made no later than six months after notification of the claim, or six months after the end of the waiting period (whichever is later). 

 

 

In a small number of claims where there are unexpected circumstances,for example where there is difficulty getting required information, a decision will be made no later than 12 months after the insurer is notified of your claim.

If your claim is for total and permanent disability, your policy may require you to go through rehabilitation or retraining.

What happens if a claim is investigated?

In a very small number of claims, an insurer will need to carry out surveillance or interviews before a claim is decided. This allows an insurer to identify potentially fraudulent claims. Fraud has an impact on everyone’s premiums, so it is important for insurers to only pay legitimate claims.

If you are required to take part in an interview, you can have a support person present, and the insurer will arrange an interpreter if you need.

The Life Insurance Code of Practice contains many important limitations and consumer protections during claims investigations, including how interviews and surveillance are carried out.

What happens if a claim is declined?

If an insurer decides to decline a claim, you will be given the reasons for this in writing. You also have the right to request the documents and information that the insurer has relied on to decide the claim.

If you disagree with the insurer’s decision, you can ask them to review the decision, and you can also access the insurer’s complaints process.

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