Income protection Claims

Transcription

1 Income protection Claims At MLC, we want to make this difficult time more manageable for you and your family. This brochure explains our claims process, what we will expect of you in relation to your claim and what you can expect from us. P R O T E C T I O N F I R S T

2 Claim form You will have most likely received this brochure with your claim form. The purpose of the claim form is to gather as much information about your injury/illness as possible so that your benefits can be assessed. The claim form includes a certificate to be completed by your treating medical professional. This should be completed in full by your doctor and submitted to us with your claim form. The assessment of your claim will begin once a completed (original) claim form is received. While we can begin assessment with a faxed copy of the form, we do require the original form. Faxed forms can be difficult to read and some doctors will require an original medical authority before providing us with some information we may request. You will have received a number of Authorities (eg. Health Insurance Commission [Medicare] authority and a Pharmaceutical Benefits Scheme [PBS] Authority) with your claim form. Please sign and return these to us as soon as possible so that if we need further information, we can immediately seek it. The purpose of the authorities is discussed in more detail in the following pages. 2

3 Your personal details We may need to write or speak to you about your claim and/or policy, therefore please keep us updated as to any changes to your address or contact details (including address). Totally Disabled, Partially Disabled and Gainful Employment At all times the conditions of the policy are paramount in the assessment of your claim. All policies will provide an explanation of what is required for you to be considered Totally Disabled or Partially Disabled. This policy condition will be what your claim will be assessed against and you should review your actual policy wording and policy schedule. Generally, the Total Disability clause in Protectionfirst policies (own occupation) includes the following requirements: 1. you must be unable to perform at least one of the important income producing duties of your regular occupation 2. you are not working in any gainful occupation, and 3. you are following the advice of a medical practitioner (Your particular policy may have different requirements. You should always refer to your policy wording.) Simply performing some tasks in your business will not automatically mean that you will no longer be considered Totally Disabled. However, the more information you provide us, the better placed our Claims Consultants will be to make a proper assessment of your claim. Naturally, we assess every claim on its merits so please keep us informed of what tasks you are undertaking. Where you do undertake income-producing tasks, you may still be entitled to a partial benefit claim. You should speak to your Claims Consultant about this if you have any questions. Financial evidence required We issue two types of policies: an Agreed Value Contract, and an Indemnity Contract With an Indemnity Contract, you need to provide evidence of your income for a period prior to becoming disabled. Your Monthly Benefit will be the lesser of the nominated benefit or an amount calculated by reference to these financial records. This will then become the Monthly Benefit for the duration of your claim while you remain Totally Disabled (subject, of course, to any Increasing Claim Benefit). With an Agreed Value contract, you nominate an agreed Monthly Benefit at the time you applied for the policy. If you provided sufficient evidence of this income at initial underwriting (or subsequently) we will not require further evidence of your income when you claim. Your policy schedule may have a statement confirming this. If sufficient evidence of your income has not been provided, you will be required to provide this when you first make a claim. Once we have accepted this evidence, your Monthly Benefit will be guaranteed at this level for the life of your policy. 3

4 Most Protectionfirst policies will also provide for benefits to continue if you are Partially Disabled. Here your entitlement is generally assessed against your Pre-Disability Earnings (as defined in your policy). Your benefit will then be a proportion of your Monthly Benefit based upon the difference between what you actually earn and your Pre-Disability Earnings. During your claim you will be paid benefits which are generally taxable under Australian Taxation Law and may need to be declared as income in your tax return. You should consult your accountant in regards to this. It is important to understand that we do not withhold tax from your payments. It is your responsibility to pay all applicable tax to the Australian Taxation Office (ATO) on benefit payments received. Some benefits (such as Critical Conditions Benefit, Scheduled Injury Benefit, Death Benefit and Child Income Benefit) may not be taxable as income and may not need to be declared. Your Claims Consultant can provide more information about this. Should your claim run for an extended period we may ask for copies of up to date taxation and other financial records to ensure that benefits have been properly declared and to ensure that you have not earned any other income, as this may affect your entitlement to benefits. As you can see, there are a number of reasons why we may request financial information and it is your responsibility to provide this information to ensure that we can continue to manage your claim efficiently and effectively. Your first payment Payments are made monthly in arrears and your first payment will be made after your Waiting Period has expired. Therefore, if you have a 30 day wait period, you may not receive a payment until 60 days after you became disabled. Where you are entitled to a Nursing Care Benefit, Accident Benefit Option, Critical Conditions Benefit or Scheduled Injury Benefit you may be entitled to payments before the waiting period expires. Ongoing claim form Your MLC policy definition will likely have two medical aspects. The first is that you suffer from an injury or sickness and the second is that you are under the care of a Medical Practitioner. In order to be entitled 4

5 to benefits you must continue to satisfy these requirements and must provide us with satisfactory evidence of this. This evidence is usually received by way of an ongoing claim form. We usually require completion of a new claim form every month. Change in circumstances During your claim you must immediately advise us of any change in your circumstances. This will include changes in your medical condition or ability to work. Medicare and PBS records Like any prudent insurer, MLC strives to ensure that premiums are kept as low as possible. One way this occurs is by ensuring that only legitimate claims are paid. In a small number of cases, policies are taken out with us where a complete medical picture has not been disclosed. To ensure that this is minimised, your Claims Consultant will review your medical history when you make a claim. This review may be as simple as comparing the information disclosed when you applied for the policy with the information provided with your claim. It will occur in all cases. In the majority of cases there is no need for any further action. In some circumstances we need a more detailed picture of your medical history. This may involve accessing your medical records from your current and past treating doctors. With your claim form you will have received a number of authorities. These authorities allow us to obtain details of your past medical history. All clients are requested to complete and sign these authorities when a claim is first made. However, we only seek access to your records if we believe there is a need to do so or our claims handling guidelines require it. Our guidelines currently provide that if a claim first occurs within three (3) years of the commencement date of your policy, your medical history will be sought from Medicare and through the PBS. As these records only provide details of consultation dates and doctors visited, following review of these records, we may need to write to some of your past and present treating doctors for further information. We will advise you of this and seek your input. Unfortunately, it does take some time to obtain these records. As such, it is important that we have the requested authorities as quickly as possible to avoid any further delays. Return to work and rehabilitation Our primary aim in the management of your claim is to ensure that you are able to commence a safe return to work as soon as possible. Many Protectionfirst policies provide a Rehabilitation Expenses Benefit. This benefit allows Protectionfirst to assist you in meeting the costs of formal rehabilitation programs and aids that you may need to return to work. These costs are met in addition to your Monthly Benefit entitlements. You should speak to your Claims Consultant about this if you require assistance. 5

6 Further medical evidence Despite receiving medical certificates from your treating doctors with your claim form, further medical evidence may be required. In these circumstances, we will use the authorities completed by you to obtain up to date and more detailed information from your past and present medical providers. Independent medical examination We may request that you undergo an examination by an independent specialist. Examinations such as these are arranged for a number of reasons, including: 1. review and confirmation of your level of disability 2. review of your treatment and management plan 3. independent confirmation of your diagnosis Any suggestions that our specialists may make will be forwarded to your treating medical providers, as they (and you) are responsible for your ongoing treatment. Provisional payments We appreciate that you have purchased this policy with us to provide financial assistance in the event that you are unable to work due to injury or sickness and that your financial commitments will continue while we assess your claim. If there is an unreasonable delay in us being able to formally accept your claim, such as due to the need to obtain Medicare or PBS records as required by our guidelines, we may agree to make provisional payments to you. Such payments are made without acceptance of liability by MLC and will be made on the basis that you agree to repay the benefits if we are unable to accept your claim. You will be asked to sign an Agreement along these lines before any provisional payments are made. We are unable to make provisional payments if we feel that we may be unable to ultimately accept your claim or where the delay in the assessment of your claim is as a result of information requested from you which we need to assess your claim. 6

7 Phone contact We encourage you to telephone your Claims Consultant and keep them advised of your condition, where possible. Your Claims Consultant is able to answer any questions you may have about your claim and your entitlements under your policy and will be only too pleased to help. From time to time your Claims Consultant may contact you about your claim and medical condition. Contact with your financial adviser In your claim form you are asked to nominate whether you permit us to disclose information about your claim to your financial adviser. If you agree, we will send copies of all important correspondence to your financial adviser and will discuss the progress of your claim with them. In that way, your financial adviser is well informed and able to assist you with any questions you may have about your claim. Complaints and assistance If you are not satisfied with a decision made in relation to your claim and would like the decision reviewed, you can send a written request to: The Claims Manager MLC Limited GPO Box 2567W Melbourne VIC 3001 Arrangements will then be made for your claim to be reviewed by our Claims Committee as part of our internal dispute resolution procedure. As soon as the Committee make a decision, you will be advised. If you are not satisfied with the decision of the Committee you may be able to lodge a complaint with the Financial Ombudsman Service (FOS) or the Superannuation Complaints Tribunal (SCT)*. These services are totally independent of MLC Limited and provide an independant dispute resolution service. The Financial Ombudsman Service contact details are: Financial Ombudsman Service GPO Box 3 Melbourne Victoria 3001 Phone: or (03) Fax: (03) info@fos.org.au Website: fos.org.au Please quote Member Number: 1018 The Superannuation Complaints Tribunal contact details are: Superannuation Complaints Tribunal Locked Bag 3060 GPO MELBOURNE VIC 3001 Phone: or (03) Fax: (03) info@sct.org.au Website: sct.gov.au * Complaints to FOS and the SCT can only be made after the complaint/claim has been through our internal dispute resolution procedure. 7

8 Ending your claim When your claim is coming to an end (such as your Benefit Period expires or you are able to return to work) payment of your premiums will re-commence. As some time may have elapsed while you are on claim, it is important to take the time to review the premium payment records we have and update us as to any changes in your payment methods (such as new account numbers, etc). This will ensure that your payments are kept up to date and your policy current. If you have any questions, or wish to check your details, you can call our Client Services Team on Privacy: By providing us with information during the course of your claim, you understand that any personal information MLC Limited ABN AFSL may collect about you in the normal course of our business may be used in accordance with our Privacy Policy. Our Policy, which is designed to protect your interests, and is consistent with the requirements of the Privacy Act, can be obtained from mlc.com.au or by writing directly to us. Disclaimer: The information in this publication reflects MLC Limited ABN AFSL understanding of existing legislation, proposed legislation, and rulings as at the date of publication. While every attempt has been made to ensure the accuracy and reliability of the information, it is not guaranteed in any way. The information in this publication is of a general nature only and does not take into account your particular objectives, financial situation or needs. MLC_AV319B_1010 MLC Limited ABN AFSL GPO Box 2567W Melbourne VIC 3001 Client Services Fax mlc.com.au 8