Health, life and income protection insurance

 
  1. Do I have to tell the company everything about my medical history?
  2. Why is it that my doctor says I can't work but the company won't pay me?
  3. How much information can the company ask me to give when I make a claim?
  4. Can the company make me go to its doctor?
  5. Why does the company prefer its doctor to my doctor?
  6. How long can the company take to accept my claim?
  7. Can I get compensation for delays by the company?
  8. Why won't the company cover the full costs of my surgery?
  9. Why does the company say my surgery is elective?
  10. What is a pre-existing condition?
  11. Is it fair that my insurance does not provide cover for pre-existing conditions?

1. Do I have to tell the company everything about my medical history?

Yes, you do. This is important information which helps the company assess your application and can affect the terms of cover it is prepared to offer you.

Many people do not know or understand what sort of medical information the company needs to know when assessing an application for life, disability or health insurance. If you are unsure or cannot remember your full medical history, you can always check with your doctor, or provide a full copy of your medical history with your application.

If you do not give the company the information it may avoid your policy and decline to consider a claim.

2. Why is it that my doctor says I can't work but the company won't pay me?

The company will only pay you if you meet the definition for "disability" in your policy. This definition is different for each policy e.g. your policy may cover you if you cannot do your job any more, or it may only cover you if you can never work in any job ever again.

This question is different to the question about whether you have a medical condition or problem. You may not able to work, but still not meet the definition for "disability" in your policy.

3. How much information can the company ask me to give when I make a claim?

You must give the company enough information to prove you have a valid claim. However, the company is entitled to obtain further information, which may include specialist medical reports or further financial information. Often this can be an ongoing process, as the company may need to ask for information from a number of people.

4. Can the company make me go to its doctor?

Yes. The company is entitled to obtain further information. This may include specialist medical reports from independent medical practitioners.

5. Why does the company prefer its doctor to my doctor?

Your doctor is usually the medical practitioner who is treating you for your medical condition. Often the company will get further information or reports from different medical specialists. The opinion of a specialist is seen as having more authority by the courts and the ISO.

6. How long can the company take to accept my claim?

It is difficult to put a time limit on how long it can take the company to assess a claim. Often the company will need to get more information from medical specialists. This usually means a wait before the specialist can make an assessment and write a report. Often this information collecting stage can take a number of months. The company is entitled to fully assess the claim and can request this information, even if you do not think it is necessary.

7. Can I get compensation for delays by the company?

The ISO has no power to award compensation for delays on the part of the company. The ISO can only look at whether the company has made a reasonable decision based on the evidence available and the decision has been make in accordance with your policy.

8. Why won't the company cover the full costs of my surgery?

The company only has to meet its obligations under the policy. Unless your policy says the company will meet all your costs, it does not have to do so. Often the company will only cover a proportion of the costs, or will pay standard costs for a procedure.

9. Why does the company say my surgery is elective?

Unless your surgery is medically necessary, the company will say that it is elective surgery. Your policy will contain details of this.

10. What is a pre-existing condition?

This is defined in the policy. There are many different definitions for pre-existing conditions. Some policies may define them as any medical condition traceable to a condition you had before taking out the policy, even if you did not know you had it. Others will define them as conditions which you knew you had before taking out your insurance.

However, this will depend on the particular company, as some will, after time, cover certain pre-existing conditions as a loyalty benefit. It is also worth remembering that if you suffer an injury or sickness, or develop a condition while you have insurance cover and you subsequently change to a new company, it is likely this will be treated as a pre-existing condition and no cover will be provided for it.

11. Is it fair that my insurance does not provide cover for pre-existing conditions?

Unless your policy offers you cover for pre-existing conditions, the company is not obliged to cover them. Generally, companies specifically exclude cover for pre-existing conditions or any associated treatment, because pre-existing conditions pose a higher risk to the company and the greater likelihood of a claim.