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How is the Insurer dealing with your TPD claim?

By 6 February 2018Compensation
superannuation injury claim

On 1 October 2016 the Life Insurance: Code of Conduct commenced operation, with a transition period until 30 June 2017. By now all Life Insurer’s are bound by and should be following the provisions of the Code of Conduct.

If you have been self-acting in a total and permanent disability (TPD) claim you may not have realised that there are many provisions within the Code of Conduct that could assist you in having your TPD assessed by the Insurer much more quickly and efficiently.

So what is the Code of Conduct? The Code provides a framework for Life Insurers (for policies such as income protection, total and permanent disability, death and trauma insurance) to standardise their conduct when dealing with and assessing claims.

The Code of Conduct covers just about all aspects of an insurance policy from product design, buying insurance, regular communications and making claims. The Code of Conduct contains principles designed to improve disclosure to policy holders, provide better transparency, decide claims within set timeframes, limit the use of surveillance and provide additional support you need to make an insurance claim.

If you are making a TPD claim then you would be most interested in Chapter 8 of the Code.

Chapter 8 – When you make a claim

There are now set timelines that the Insurer must comply with:-

  1. Within ten (10) business days of being notified about your claim, the Life Insurer will explain to you your cover and the claim process.
  1. Prior to making a decision on your claim, the Life Insurer will keep you informed about the progress of your claim at least every 20 business days.
  1. The Life Insurer will respond to your requests for information about your claim within ten (10) business days.
  1. If the Life Insurer requests a report from an Independent Service Provider, the Life Insurer will require the report to be provided within four (4) weeks.
  1. Once the Life Insurer has all the information to assess your claim they will let you know their decision on your claim within ten (10) business days.
  1. The Life Insurer will let you know their decision no later than six months after they are notified of your claim or six months after the end of any waiting period, unless unexpected circumstances apply. Where unexpected circumstances apply, their decision will be made no later than 12 months after they are notified of your claim.

When performing assessments the Life Insurer will only ask for and rely on information and assessments that are relevant to your claim and policy, for example, financial, occupational and medical information. If you disagree with the relevance of any information, the Life Insurer will review your request, and if you are not satisfied with the review you can make a complaint.

The Life Insurer can ask you for a written authority to obtain information from doctors, treatment providers and your employer. If you are concerned with access to private information you can instead authorise the Life Insurer to request particular information from particular sources, however, this may cause delays in the assessment of your claim.

If the Life Insurer needs you to attend an independent medical examination:

a) the Life Insurer will meet the cost of the appointment (excluding missed appointment fees), production of any reports and extraordinary travel costs agreed in advance;

b) you can request copies of your independent medical examination report(s);

c) if you request, you can choose from a list of doctors the Life Insurer nominates for your independent medical examination.

The Life Insurer may from time to time conduct surveillance on you. If they do then the Code puts in place certain guidelines:

a) alternative methods of verifying information will be sought prior to arranging surveillance;

b) surveillance will only be arranged where the Life Insurer reasonably believe prior to carrying out the surveillance that your claim appears to be inconsistent with information available to them;

c) the investigator will not intentionally film people in the company of you, and where this cannot be avoided, any footage of people in your company will be pixelated or blurred;

d) the Life Insurer will discontinue surveillance where there is evidence from an independent medical examiner that it is negatively impacting your recovery; and

e) surveillance investigators will not communicate with neighbours or work colleagues in ways which might directly or indirectly reveal that surveillance is being, will be or has been conducted.

If you need help with your TPD claim, the Life Insurer is not complying with the set timelines, or you can’t quite get your head around the Code of Conduct then contact one our superannuation solicitors on 13 58 28.