A follow up investigation (released on August 30 2018) by the Australian Securities and Investment Commission (ASIC) went further into the issue of poor claims outcomes. This time focusing on ‘direct life insurance policies’.
Below is a summary what the ASIC’s found, along with tips on how you can avoid being part of these statistics:
Policy cancellation rates were sky high
With 37% of buyers not aware that their premiums would increase every year, it’s no wonder people cancelled.
The percentage of denied claims for direct life insurance was almost 10% higher than for life insurance as a whole. Two-thirds of direct buyers didn’t even fully understand their policies exclusions.
When you buy direct, understand that your pre-existing conditions will most likely not be covered. If you do have a pre-existing condition, look for a direct policy that offers a detailed medical questionnaire at the start.
This may take longer to get cover but you’ll be more certain at claim time. Or, consider buying policy through an adviser who can help create a custom policy for you.
Poor sales conduct leading to 'negative consumer outcomes'
A massive 63% of direct policies sold over the phone were cancelled within three years.
If someone tries to sell you a policy, don’t buy it unless you have received a product disclosure statement (PDS) and you are 100% aware of the exclusions.
Customers who were rejected for one policy were sold a different one with a lot more exclusions
If a customer’s application was rejected, sales reps would then offer an 'automatic acceptance' or off-the-shelf' policy.
If you ever have to downgrade, just be aware that the downgraded policy will have a lot more exclusions. It’s a good idea to get these exclusions in writing.
Insurance companies were raking in the dough with accidental death insurance
This is a type of insurance that covers you only if you die in an accident. Of these policies, the amount insurers spent paying claims was only 16% of the cash they brought in, indicating that these policies aren't fully understanding what they are signing up.
Previous updates: 5 April 2018
The Life Insurance Industry under pressure to 'do better'.
The steps involved for you and your adviser include:
1. Determining the type of cover. That is, how much cover you need, what type, the right brand, how to structure and the right type of benefits for you.
2. Completing and submitting an application form. This asks questions about your health, financial situation, lifestyle and pastimes
3. Having your lifestyle statements and medical history assessed. Insurance underwriters will assess factors such as age, health, cover applied for and sum insured, and supplying any additional information required such as a letter from your doctor or a medical exam
4. Agreeing to any revised terms. These are proposed by the insurer. If an agreement cannot be reached then the application process is ended.
5. Receiving the policy and confirming cover. This will include details such as sums insured, any special conditions or exclusions and cover commencement and end dates
Why are the steps sometimes so detailed?
The reason the application process is so thorough when using a financial adviser is because the underwriting is sometimes done at the time of application, unlike many policies bought direct from the insurer where the underwriting occurs at the time of making a claim.
Additionally, an adviser will take you through each step meaning a more thorough approach is taken.
The steps involved in applying for a life insurance policy direct from the insurer are typically straightforward, which is why such policies are becoming increasingly popular. In many cases, you will:
1. Go online
2. Complete an online medical questionnaire
3. Provide personal details, employment status
4. Agree to duty of disclosure
5. Agree to an exclusion clause for pre-existing medical conditions, suicide, self inflicted injuries, dangerous jobs and life styles and genetic conditions.
6. Cover is activated
By contrast, applying for life insurance through an adviser involves a lot more questions and health-related declarations, possibly including a request for a medical examination and the provision of a full medical history.
Direct from the insurance website or over the phone
From a sales partner, agent or affiliate of the insurer such as a bank
Via a telephone or email marketing company acting on behalf of the insurer
Important questions to consider
No medical exam is required for a policy purchased direct from the insurer for the same reason that no other health-related questionnaires or declarations are needed: because the policy is one-size-fits-all. In place of any detailed underwriting, such policies contain a pre-existing conditions clause (see below) which only comes into effect at the time of making a claim.
This clause stipulates that no benefit is payable if the reason for the claim existed at the time of taking out the policy. In other words, if you had a heart condition at the time of applying (even though there was no questionnaire) a subsequent claim related to a heart problem would probably not be paid.
As well as the pre-existing conditions clause, other potential drawbacks with policies purchased direct from the insurer can include:
Basic nature. Because the policy has no up-front underwriting, it is usually very basic, offering few benefits and providing only limited cover.
Direct claiming. The insured or their beneficiaries must claim directly from the insurer at a time of loss and emotional distress, whereas an adviser can act on the insured’s behalf in managing the claims process with the insurer.
More exclusions. Direct policies generally have more automatic exclusions than advised policies.
Despite it's drawbacks, there are some advantages to direct life insurance policies. For instance, the application process is fast and easy and if you are in good shape, it can be a convenient way to purchase insurance.
Additionally, not all direct policies are one-size-fits-all. Some insurers offer more tailored products that are partially underwritten during application, such as Virgin Money’s retail product, which offers a reduction in premiums in return for more information regarding your health and lifestyle.
Some direct policies are tailored
Note: Some direct policies will offer a “tailored” option which underwrites during the application process instead of making assumptions and underwriting at claim time.
Insurance inside super
Did you know you may have already have life insurance?
Many people aren’t aware that they may have life insurance as part of their superannuation that is provided to a group of people (e.g. employees). Many super funds provide a default level of life, TPD and income protection cover for their members. You will usually have the option of either:
Increasing this level of cover, or
Opting out of cover altogether and thereby keeping more money in your retirement fund
What are the common traps to be wary of?
The recent ASIC investigation into life insurance highlighted disclosure problems between fund trustees and their members.
A common complaint from people holding life insurance through their superfund is that the communication between them and the trustee of the super fund is often infrequent and unclear. Many policyholders are:
Unaware that they even have life cover
Unsure of how much cover they have
Unsure of what their options are in relation to this cover
Unaware of what changes will void their cover
The recent ASIC investigation into life insurance highlighted disclosure problems between fund trustees and their members. ASIC indicated it would be looking into this issue in the future.
The amount of life insurance cover you have through your super will be at the discretion of the fund’s trustees, but generally it will only be a rudimentary amount, which is why many members opt to increase their level of cover.
Having life insurance through super is a way for everyone to have some level of cover, particularly those who can’t afford standalone cover, but the downside is that if you leave your job, coverage may not follow you and you may find yourself without any life insurance at all.
One way to avoid losing your coverage and to increase your cover to a more adequate level is to perform a superannuation rollover.
This involves transferring money from your super fund into an independent insurer’s superannuation life cover plan. This money can then be used to pay your premiums for life, TPD and income protection cover.
Pre-existing medical condition? Make sure you read this.
Although many super funds provide automatic qualification for group life insurance with no medicals required, there are still situations when claims are denied on the grounds of pre-existing medical conditions. Exclusions can apply to existing conditions if you:
Are not working when the cover begins
Have taken more than 10 days of sick leave in a row in the last 12 months
Transfer to a new fund that excludes pre-existing medical conditions
Are you eligible to receive a payment from another source
Increase your cover
Change occupation category
Applying the right way
In order to obtain a policy that is clear with what they will and won't cover you for, it's important to disclose relevant personal information upfront. To maximise the likelihood of you being able to make a claim, be sure to have the following types of personal details on hand when you apply:
Your height and weight and whether you have gained or lost weight in the past 12 months
Whether you have ever had or experienced symptoms of a range of listed conditions, even if you have not seen a doctor about them
If you are male, whether you have had any disorder or problem of the prostate or testicle
If you are female, whether you have ever experienced any complications with pregnancy or childbirth (if you are currently pregnant), received abnormal pap smear results or had lumps or pain in your breasts
Whether in the last five years, had any other medical tests, used any other medications or had any other illness or injury that has prevented you from working for more than three consecutive days
Whether you have had a genetic test and if so, what the results were
Whether you have ever been admitted to hospital for any reason
If you are currently experiencing any symptoms or complaints for which you have not consulted a doctor
If you are awaiting any medical advice, investigation or treatment including surgery
Whether you or any of your current or previous sexual partners have tested positive for HIV/AIDS
You will also be asked for details of your family history, which might typically include:
Whether any of your first degree (blood-related) family members have ever had any of a list of conditions such as stroke, diabetes, heart conditions and Alzheimer’s disease
Whether you are required to have any regular screenings due to your family history or if you have any tests or investigations pending
Details of your sports and pastimes will also be required to further determine your level of risk and these might include:
Most advised life insurance policies require a detailed application with a lot of questions designed to tailor your cover.
Only some direct life insurance policies offer a tailored option. It is also your responsibility to decide what policy and level of cover is right for you.
Traps to watch out for in the application process
These traps could bite you in the back at a later stage. Some common mistakes people make when filling out policy applications can include:
Failing to understand the definitions of terms within the policy
Failing to disclose all relevant information to the insurer at the time of application
Failing to understand the eligibility requirements for making a claim
Failing to answer application questions correctly or accurately
Who might struggle to get full cover?
Some groups of people might find it difficult to qualify for full life insurance including:
Anyone who has a pre-existing medical condition (within five years before applying for cover)
Anyone with a history of suicide attempts
Anyone who has a dangerous occupation
Anyone who participates in a hazardous pastime or sport
Anyone with a known genetic condition
Does this mean I simply can't get insurance?
If you fall into one of these groups then you'll either:
Have to pay a loading on your premium and receive full cover
Receive cover with special exclusions or conditions
Be excluded all together from cover (not always the case)
Should I just keep these details a secret?
No. It's in the best interest to disclose everything. The insurer will decide whether or not to cover you and offer you specific terms. Remember, failure to disclose can usually lead to a claim being denied or your policy being cancelled later.
Preparing your policy for the future
What should I check before I purchase a policy?
There would be nothing more emotionally and financially frustrating than to pay premiums on insurance for a number of years only to discover that you have never been eligible to claim. This could happen unless you check your eligibility before you purchase your policy.
During the application: Check the exclusions on your policy
Exclusions that could restrict your ability to claim from the get-go can include:
Pre-existing conditions. Having a pre-existing medical condition that is excluded from cover.
Certain employment categories. Being in an excluded employment category (e.g. casual work, dangerous jobs) when applying for income protection cover.
Non-residency. If you're not Australian citizen or resident, as this is often an eligibility requirement.
Understand the key definitions
Check your policy's definition for these common conditions before you buy. It's important to understand that these definitions will vary between insurers.
TPD (Total and Permanent Disability) insurance is a component of life insurance that provides long-term financial compensation if you cannot return to work due to total and permanent disablement.
How do TPD requirements vary with insurer
Eligibility requirements vary with insurers, and criteria where differences may occur include:
The definition of disablement. Can vary from being “unlikely to ever work again” and “unlikely to ever be engaged in any occupation” to “likely to be disabled for life”
The waiting period for eligibility. Can vary from “a six-month continuous absence from work” to “being out of work for at least three consecutive months”
The period in work before the TPD event. Can vary from being “engaged in 12 consecutive months’ work before the event” to “engaged in full-time gainful occupation immediately before the event”
The ongoing care requirements. Can vary from “following the advice and care of a specialist” and “taking steps to avoid further illness or injury” to being “under the regular care of a medical practitioner”
Trauma insurance provides cover if you are diagnosed with a specified illness or injury such as cancer or a stroke that is likely to have a significant impact on your life. Like TPD cover, definitions of terms vary with insurers, making close examination of the policy vital for determining eligibility to claim.
How do trauma requirements vary with insurer
Trauma-related variations can include:
Diagnosis of heart attack severity. Prescribed diagnostic tests can vary, depending on the insurer.
Diagnosis of stroke. Onset timeframes, the type of medical specialist required and the prescribed diagnostic tests can all vary with insurers.
Diagnosis of severe rheumatoid arthritis and multiple sclerosis. The type of medical specialist and diagnostic criteria can vary with insurer.
Diagnosis of cancer. There is great complexity in the definitions of cancers by insurers and terms vary widely.
What if I have a pre-existing medical condition?
A pre-existing medical condition is generally regarded as a condition you are aware of at the time of applying for insurance. Depending on its severity, insurers will often cover the condition (often for an additional fee) if you declare it at the time of application. However, if you fail to declare it and then make a claim for an illness or injury related to that pre-existing condition, it is likely your claim will be rejected.
Percentage of disputes involving the definition of pre-existing conditions
What counts as a pre-exiting medical condition?
While the meaning of a pre-existing condition is broadly understood, its specific definition can vary with insurers, so careful examination of the terms used in your particular policy is always important. For instance, a pre-existing medical condition can include (but is not limited to):
An injury or illness you were diagnosed with, had symptoms of or were treated for prior to the policy’s inception
Health conditions for which you needed to consult a medical practitioner or other health professional
Conditions where the symptoms would have caused an ordinarily prudent person to seek diagnosis, care or treatment
How do I avoid claim disputes involving pre-existing conditions?
Because the onus is on the applicant to declare their pre-existing conditions, disputes between policyholders and insurers who refuse to pay claims often involve medical conditions which the insurer considers pre-existing.
This may include conditions which the policyholder:
May not even have been aware of
May have considered too trivial to be declared
May have considered too long ago in their past
May not have had formally diagnosed by a doctor
If you need to make a claim
Follow these steps to ensure your claim goes smoothly
What are the initial steps involved in a life insurance claim?
While claims procedures vary with insurers and policy types, the initial steps involved in making a life insurance claim are typically the same. The insured or their beneficiaries contact the insurer and notify them of their intention to make a claim and the insurer conducts an initial assessment of the claim.
What are the key follow-up steps after you submit a claim?
Typically, within 10 days of being notified of the pending claim, the insurer will provide the insured with a claim form if one has not already been lodged. Then, once the claim form has been lodged along with the necessary accompanying documentation, the insurer will assess the claim in detail and decide whether it will be paid or whether more information is needed. If after examining all the evidence, the insurer denies the claim, they must provide written reasons to the claimant and inform them of their right to request a review of the decision.
What documentation will I need to provide?
Each type of cover will require you to provide different kinds of evidence in support of a claim.
If claiming for a death, you will need to provide:
The deceased’s ID
Letters of administration.
Proof of your own identity
Your relationship to the deceased
Your financial dependence on the deceased
Copies of any financial settlements between you and the deceased (where applicable).
For employees, you will need:
Evidence of your income including a group certificate
Personal tax return
Personal tax assessment notice
If you are self-employed, you will need a:
Business profit and loss statement
Business balance sheet
Business tax return
Business assessment notice
If claiming for a specified major illness, you will typically need to provide:
Documents confirming diagnosis of the illness
A Medicare report of your recent billed consultations
Treating doctor’s consultation report.
Reports from other insurers
Additionally, your insurer may request a review of your condition by a specialist consulting doctor if considered necessary.
If claiming for total and permanent disability, you will typically need to provide:
A Medicare report of your billed consultations
A treating doctor’s report
Reports from other insurers
A worker’s compensation report
You may have to undergo an independent medical examination and an employability assessment by an appropriate consultant.
How long will my claim take to be processed?
Average time taken for one insurer
Source: ASIC 2016
The timeframe for a claim to be processed varies with insurers and policy types and is dependent on a range of factors such as:
The type of cover
Whether waiting periods are involved
The ability of the insurer (or trustee for group insurance) to manage and assess the claim
The complexity of the claim
The timely provision of supporting evidence
Whether there is anything that needs investigation
Not satisfied with the outcome of your claim?
If a claim doesn't go as you expected, you still have options.
Internal dispute resolution
If you are unsatisfied with a claim outcome, the first thing you can do is to complain to the insurer through their internal dispute resolution (IDR) process. As licensed financial services, all insurers are required to have such a process in place and they must attempt to resolve the dispute with you directly in the first instance.
External dispute resolution (EDR)
If you are unhappy with the outcome of the internal dispute resolution process, your next option is to seek help from an external dispute resolution (EDR) scheme. This is a free, independent consumer service that provides an alternative to going to court.
Australian insurers are required to be members of an ASIC-approved EDR scheme such as the Financial Ombudsman Service (FOS). Such a scheme can resolve your dispute through negotiation and if it sees fit, it has the power to make a binding decision on the insurer which could result in you receiving financial compensation. This is not always the case though and their main role is to seek a mutually agreeable solution, which in some cases may involve something as small as an apology from the insurer.
If you are unhappy with an EDR decision on your case, your next and final recourse is to take the matter to court, which may only be advisable if the amount in dispute is substantial.
Superannuation Complaints Tribunal (SCT)
If your complaint relates to group life insurance held inside superannuation, the Superannuation Complaints Tribunal (SCT) may be able to help. The Tribunal deals with complaints about the conduct and decisions of trustees, insurers and other decision-makers in relation to superannuation and typical complaints can include:
Incorrect allocation of benefits
Unreasonable payment delays
Miscalculation of a benefit or payment
Refusal to approve a claim
Misrepresentation of terms and conditions
Errors in annual statements
If the Tribunal decides it is able to deal with your complaint, it will attempt to resolve it through conciliation by reaching a mutually agreeable settlement between all parties. If conciliation is unsuccessful, the Tribunal will then review the complaint and make a decision, which is binding on all parties and enforceable by the Australian Securities & Investments Commission (ASIC).
If a scheme such as the Financial Ombudsman Service (FOS) decides in favour of your insurer, you are not bound by their decision and still have the right to take your complaint to court. But if it is a small dispute, this may not be worth your while, as court cases can be very expensive with no guarantee of winning.
If the dispute involves a large amount and you are determined to take the matter further, the best advice would be to consult a lawyer, who can quickly determine whether you have a good case to take to court.
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