Declined claims due to pre-existing conditions are most often seen in the group critical illness market, adds White. But even then, they are minimal.
The latest Grid claims survey evidenced that 99.8 per cent of life claims were admitted, over 90 per cent of group IP claims were admitted and almost all declines were due to not meeting the definition of disability.
For group critical illness, of over 1,180 claims submitted, around 185 were declined as a result of not satisfying the pre-existing / related conditions clause.
What can go wrong with individual claims?
Back to the individual market and once on risk, the reason that most, potentially valid, claims go wrong seems to be due to the policyholder failing to inform their adviser or insurer about significant changes in circumstances that could affect the level of any potential future payouts – for example, a fall in income.
“This still happens even though we send out regular emails reminding people to get in touch if there is a fall in income,” says Tom Conner, director at Drewberry. “It’d be good to see all insurers guarantee an element of cover to avoid severe situations of this sort, possibly up to £1,500 a month.”
Mr Conner would also like to see a better process of sorting out discrepancies over medical information.
“There often seems to be discrepancies between medical notes and the discussions GPs have with their patients. Unless they disagree, insurers tend to take GP notes as gospel when I’m not convinced they’re always up to date or completely accurate. This is a difficult and potentially sensitive one to tackle.
“A particularly frustrating one is where the insurer’s chief medical officer doesn’t agree with the client’s GP or consultant about the severity of their condition. A process should be in place for the CMP to use specialists in making their decision.”
In the past, paper-based claim forms contributed to the problem of claims not being paid because insufficient information was provided. This problem is largely overcome these days by the fact that most claims are taken over the phone by experienced clinicians.
“With advance listening skills and empathy, it’s possible to gain a greater understanding of the individual’s condition,” says Mr Gething.
“The latest innovation is to combine the claim processing with counselling and other talking treatments so the claim process itself helps the consumer embark on the appropriate treatment and get better, rather than contributing to their stress.”
