CASE STUDIES
Reasons why Risk Assist Claims Management
SHOULD REPRESENT
YOU
Reasons why Risk Assist Claims Management
SHOULD REPRESENT
YOU
case study 1 - Trauma/Critical Illness claim after suffering a Heart Attack
![Picture](/uploads/5/2/5/0/52500041/published/download-3.jpg?1485318161)
Client 'A' was unfortunate enough to have experienced a heart attack whilst at home and was rushed to hospital, where he was monitored and treated for his condition. After making a significant recovery he was released from hospital and returned home.
He then contacted his Insurance Adviser to discuss how he could make a claim on his insurance policy. The Adviser arranged for claim forms to be issued to Client 'A' and told him to complete them and return them directly to his Insurance Company. This advice could have easily cost Client 'A' a potential claim settlement.
However, Client 'A' approached us to review his completed forms before submitting them to his Insurer. Client 'A' was looking to claim under the definitions for Heart Attack. After reviewing the content, It was clear that the claim would have been declined as he did not met the definition under his policy based on the information provided in the claim forms and the lack of supporting medial evidence.
After further discussion with Client 'A' and reviewing his options, we were able to obtain additional supporting medical evidence in the form of an electrocardiogram showing that Client 'A' had a secondary cardiac arrest (cardiac asystole) whilst in the ambulance on the way to hospital. We were then able to assist Client 'A' to complete new claims forms based on this information, which subsequently lead to a successful claim under the definition of Cardiac Arrest (out of hospital).
case study 2 - income protection CLAIM for a fractured wrist
![Picture](/uploads/5/2/5/0/52500041/published/accident-injury-claim.jpg?1485318153)
Client 'B' suffered a fracture to his wrist whilst a work, so called to advise us of his situation and so we could determine if he was able to make a claim under his Income Protection insurance policy. After checking his policy, I was able to determine that he had the ability to lodge a claim under the specific injury benefit.
Having contacted the Insurance Company to request claim forms on behalf of Client 'B'. The telephone representative who took the call asked further questions prior to releasing claim forms; What was the injury? How did it had occurred? What was Client 'B' last working day? - Nothing abnormal there!
However to my surprise I was then told by the Insurance Company that Client 'B' was not able to make a claim until he had completed his 30 day wait period. I had to explain that Client 'B' had suffered a fracture to his wrist and under his policy he met the definition for a specific injury and as such was entitled to lodge a claim.. The insurance company's representative remained adamant that a fractured wrist was not a specific injury, he only agreed to released claim forms when I had had advised him to check the relevant PDS definitions for injuries covered under the specific injury benefit.
This clearly shows that if Client 'B' had contacted the Insurance Company directly and had not being fully aware of the claimable benefits under his policy, he could have quite easily believed that he did not have a valid claim at that time. In this case, this wrong information could have cost Client 'B' $15,000. Luckily he had a knowledgeable claims consultant working on his behalf and was pleased to received his full benefit within a few days of lodgement of his claim. Client 'B' understands the importance of having a specialist claims consultant manage his claim.
Having contacted the Insurance Company to request claim forms on behalf of Client 'B'. The telephone representative who took the call asked further questions prior to releasing claim forms; What was the injury? How did it had occurred? What was Client 'B' last working day? - Nothing abnormal there!
However to my surprise I was then told by the Insurance Company that Client 'B' was not able to make a claim until he had completed his 30 day wait period. I had to explain that Client 'B' had suffered a fracture to his wrist and under his policy he met the definition for a specific injury and as such was entitled to lodge a claim.. The insurance company's representative remained adamant that a fractured wrist was not a specific injury, he only agreed to released claim forms when I had had advised him to check the relevant PDS definitions for injuries covered under the specific injury benefit.
This clearly shows that if Client 'B' had contacted the Insurance Company directly and had not being fully aware of the claimable benefits under his policy, he could have quite easily believed that he did not have a valid claim at that time. In this case, this wrong information could have cost Client 'B' $15,000. Luckily he had a knowledgeable claims consultant working on his behalf and was pleased to received his full benefit within a few days of lodgement of his claim. Client 'B' understands the importance of having a specialist claims consultant manage his claim.
case study 3 - Pay & Close Claim after surgery 18 MTHS AGO
![Picture](/uploads/5/2/5/0/52500041/published/risk-assist-winner_1.jpeg?1485317884)
Potential Pay & Close Claims available to your clients during review or renewal of policies
Christmas time is the one time a year when finances are always a little tight; we over spend, over indulge and then generally have a BIG credit card debt to show for it – Well I know I do !!!
Being able to assist clients in successful claims is always a joy, no more so than at this time of year.
I wanted to share my story of one such claim…
My client who had undergone surgery in June of 2015, yes 18 months ago! was referred to me by a Risk Advisor when looking at reviewing his cover. During this review the client confirmed that he had undergone back surgery however at the time he did not make a claim, as his previous Advisor had informed him that they could request claim forms but as he was only off work for a few weeks, it would not be worth him making a claim!
SERIOUSLY! The client was off work for 8 weeks, with a 30 day wait period.
I was able to lodge a ‘Pay & Close” claim with his insurance company, OnePath, who were flexible in my request to waive the financial requirements for the indemnity policy and even paid an additional $1,671.00 in ‘No Claim Benefit’ which resulted in a payout of nearly $7,000 within less than a week of lodgment. I would like to say a BIG thank you to all the claims staff who worked throughout the Christmas/New Year period to ensure clients claims, like mine, were dealt with smoothly and efficiently.
Next time you are reviewing or renewing cover for new and existing clients, don’t forget to check if they are able to make a claim for an injury or illness they have experienced since their policy was last reviewed/renewed. Quite often the client is unaware of their ability to claim or they just find the whole process too difficult. If this is the case, why not contact me and I would be more than happy to assist them in lodging a claim for any potential benefits that they may be entitled to…. Call me on 1300 644 980.
- Published on LinkedIn January 9, 2017 by
Christmas time is the one time a year when finances are always a little tight; we over spend, over indulge and then generally have a BIG credit card debt to show for it – Well I know I do !!!
Being able to assist clients in successful claims is always a joy, no more so than at this time of year.
I wanted to share my story of one such claim…
My client who had undergone surgery in June of 2015, yes 18 months ago! was referred to me by a Risk Advisor when looking at reviewing his cover. During this review the client confirmed that he had undergone back surgery however at the time he did not make a claim, as his previous Advisor had informed him that they could request claim forms but as he was only off work for a few weeks, it would not be worth him making a claim!
SERIOUSLY! The client was off work for 8 weeks, with a 30 day wait period.
I was able to lodge a ‘Pay & Close” claim with his insurance company, OnePath, who were flexible in my request to waive the financial requirements for the indemnity policy and even paid an additional $1,671.00 in ‘No Claim Benefit’ which resulted in a payout of nearly $7,000 within less than a week of lodgment. I would like to say a BIG thank you to all the claims staff who worked throughout the Christmas/New Year period to ensure clients claims, like mine, were dealt with smoothly and efficiently.
Next time you are reviewing or renewing cover for new and existing clients, don’t forget to check if they are able to make a claim for an injury or illness they have experienced since their policy was last reviewed/renewed. Quite often the client is unaware of their ability to claim or they just find the whole process too difficult. If this is the case, why not contact me and I would be more than happy to assist them in lodging a claim for any potential benefits that they may be entitled to…. Call me on 1300 644 980.
case study 4 - Wrong information given by the insurance company
![Picture](/uploads/5/2/5/0/52500041/published/try-again_1.jpg?1491286880)
A client suffered a fracture to his wrist whilst at work and made a call to his adviser to see if he could make a claim.
This was then passed to myself and after completing the due diligence stage, checking his policy schedule & PDS, I was able to determine that he had the ability to lodge a claim under the specific injury benefit with his insurer.
Having contacted the Insurance Company to request claim forms on behalf of the Client, the telephone representative who took the call asked further questions prior to releasing the claim forms; What was the injury? How had it occurred? When was Clients' last day of work? - Nothing abnormal there!
However, to my surprise, I was then told by the insurance company that our Client was not able to make a claim until he had completed his 30 day wait period.
I once again explained that the Client had suffered a fracture to his wrist and under his policy he met the definition for a specific injury and as such was entitled to lodge a claim, irrelevant of his wait period. The insurance company representative remained adamant that a fractured wrist was not a specific injury, only agreeing to release the claim forms when I suggested he checks the PDS definitions for injuries covered under this benefit along with the exact page number!!
This just goes to show, If the client had not come to me but had contacted the Insurance Company directly and had not been fully aware of the claimable benefits under his policy, he could have quite easily believed that he did not have a valid claim at that time. In this case, this would have cost the client $15,000 in paid benefits.
This was then passed to myself and after completing the due diligence stage, checking his policy schedule & PDS, I was able to determine that he had the ability to lodge a claim under the specific injury benefit with his insurer.
Having contacted the Insurance Company to request claim forms on behalf of the Client, the telephone representative who took the call asked further questions prior to releasing the claim forms; What was the injury? How had it occurred? When was Clients' last day of work? - Nothing abnormal there!
However, to my surprise, I was then told by the insurance company that our Client was not able to make a claim until he had completed his 30 day wait period.
I once again explained that the Client had suffered a fracture to his wrist and under his policy he met the definition for a specific injury and as such was entitled to lodge a claim, irrelevant of his wait period. The insurance company representative remained adamant that a fractured wrist was not a specific injury, only agreeing to release the claim forms when I suggested he checks the PDS definitions for injuries covered under this benefit along with the exact page number!!
This just goes to show, If the client had not come to me but had contacted the Insurance Company directly and had not been fully aware of the claimable benefits under his policy, he could have quite easily believed that he did not have a valid claim at that time. In this case, this would have cost the client $15,000 in paid benefits.
case study 5 - be aware of "no Win - no fee"
![Picture](/uploads/5/2/5/0/52500041/published/specter.jpg?1491287246)
In this case study, A good friend of mine who is in fact a lawyer himself, had a client who engaged a well-known Law Firm to lodge his Trauma Claim after being diagnosed with cancer. Having seen the TV media coverage on declined claims, he chose to have the Law Firm represent HIS claim thinking that it would improve his chances of a win. The firm regularly advertised on his local radio and TV channels ‘No Win – No Fee Insurance claims due to injury or illness’.
Upon receipt of the claim lodgement from the Law Firm, the insurance company automatically engaged their own legal department to review and respond, completely bypassing the normal claim assessment process. With a lot of to-ing & fro-ing, the claim took in excess of 6 months to be accepted. In comparison, an average trauma claim should be assessed and paid within a month. This resulted in a charge of $50,000 in legal fees. Even though the claim was paid, the client only received $60,000 of a total $110,000 trauma benefit. I ask you, Is this truly a WIN?
Unfortunately, this is not an isolated case; these type of scenarios are becoming all too common.
Just because a client has engaged a lawyer it does not necessarily guarantee a successful outcome however it does guarantee increased timeframes and costs.
Upon receipt of the claim lodgement from the Law Firm, the insurance company automatically engaged their own legal department to review and respond, completely bypassing the normal claim assessment process. With a lot of to-ing & fro-ing, the claim took in excess of 6 months to be accepted. In comparison, an average trauma claim should be assessed and paid within a month. This resulted in a charge of $50,000 in legal fees. Even though the claim was paid, the client only received $60,000 of a total $110,000 trauma benefit. I ask you, Is this truly a WIN?
Unfortunately, this is not an isolated case; these type of scenarios are becoming all too common.
Just because a client has engaged a lawyer it does not necessarily guarantee a successful outcome however it does guarantee increased timeframes and costs.
Disclaimer: The above are examples of real life cases that have been managed by Maria Longland.
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