8. General overview & principles of claims

Question 1

What is the first thing the claims department needs to do when receiving a claim?

Answer 1

They need to verify the information.

Question 2

What is the purpose of verification?

Answer 2

To make sure there is no form of non-disclosure.

Question 3

Name 5 particulars that are part of the verification process?

Answer 3

1. Age & Gender
2. Smoking status
3. Occupation
4. Part-time activities
5. Health aspects

Question 4

What can be the consequences of non-disclosure?

Answer 4

The claim can be repudiated.

Question 5

What needs to be considered to establish whether a claim is valid or not?

Answer 5

1. Whether the condition is covered.
2. Whether the cause of the condition falls within the benefit.
3. Whether the cause of the condition is the proximate cause or not.

Question 6

How does insurers deal with early claims?

Answer 6

Early claims falls outside the norm which means that insurers will deal more thoroughly with the claim and its information exactly for that reason.

Question 7

How do life insurers handle death by suicide?

Answer 7

Most life insurers have a 24 months suicide clause which states that if a member commits suicide within 24 months the claim would be repudiated.

Question 8

How do life insurers handle death by suicide after a reinstatement?

Answer 8

The same suicide clause will be in place except the suicide clause will reset upon reinstatement.