Note: “Anna” is a pseudonym used to protect the customer’s identity. This story is shared with the customer’s permission to illustrate the challenges faced and the support provided.
Claiming income protection insurance can often feel like maneuvering through a maze, with each turn presenting new challenges and obstacles. This complexity is exacerbated when processes don’t fully account for each customer’s unique circumstances. At Simplify My Claim, we specialise in guiding clients through this intricate maze, providing expert advocacy and support to ensure they receive the fair treatment they deserve.
Anna’s experience is a compelling example of why our work is so crucial. Facing the possibility of an unjust claim denial, Anna found herself overwhelmed by the intricacies of the insurance system. That’s where Simplify My Claim stepped in, offering the essential support and advocacy needed to secure a just and equitable outcome.
Assessing Policy Terms vs. Real-World Scenarios
It’s important to acknowledge the challenging role that claims assessors play. Drawing from extensive experience working within life insurance claims teams, we have a deep respect for the complexities these professionals navigate daily. Claims assessors must apply complex policy terms and navigate intricate processes while adhering to stringent compliance requirements, upholding service standards, and following Life Code Obligations. On top of these responsibilities, they support customers during their most challenging and emotional times, often dealing with significant health and personal issues. This can lead to becoming emotionally invested in devastating situations and, at times, facing unwarranted abuse as customers express their frustration, all of which requires exceptional resilience.
The story of Anna is not a critique of the individual assessor involved, who was courteous, professional, and respectful throughout the process. Rather, it highlights the broader challenges claims assessors face when policy terms and internal processes fail to align with real-world scenarios.
Anna’s journey raises critical questions:
- Are product and policy terms consistently crafted with real-world application in mind and aligned with the claims philosophy, or are they developed in isolation with a primary focus on pricing considerations?
- Are claims assessors sufficiently trained to understand both the letter and the intent of policy terms, as well as the underlying claims philosophy?
- Are they given enough latitude to assess claims in a way that considers the customer’s full circumstances and aligns with the claims philosophy, beyond just a literal interpretation of policy language?
- Do internal processes support assessors in making holistic, fair decisions with the empathy required by the claims philosophy, or do they compel them to default to rigid policy interpretations?
Anna’s Challenging Experience
Anna’s situation was complex. She had been managing a health condition that significantly impaired her ability to work. Despite these challenges, she continued fulfilling her duties, largely thanks to an understanding employer who provided the necessary flexibility to accommodate her condition. Anna was working on a fixed-term contract, and driven by a strong work ethic and a desire not to let her employer down, she pushed herself until her doctor advised that it was time to prioritise her health and rest. She received certification to cease work, which happened to coincide with the approaching end of her contract. After several months off, Anna reluctantly came to the decision that she needed to submit a claim on her income protection policy—something she had hoped to avoid, felt embarrassed about, and found deeply distressing.
The Insurer’s Narrow Interpretation
From the outset, the insurer considered denying Anna’s claim, relying on a narrow interpretation of her circumstances. The policy required that a person be “gainfully employed” on the date of disablement. In Anna’s case, the insurer determined that this date was the day after her contract ended, disregarding being certified unfit for work on the date prior to her contract ceasing and continuously for the following nine months, her evident struggles to keep working, and the accommodations made by her employer—all of which clearly indicated her inability to undertake her material and substantial duties before her contract actually concluded. This date also happened to fall on a Saturday, meaning that even if Anna had a new role starting with a different employer on the following Monday, the literal interpretation of the policy would have resulted in her claim being denied. This highlighted, in our view, a significant gap in the insurer’s coverage for customers transitioning between jobs or whose contracts had ended. Whether it’s a single day or more, being temporarily unemployed would mean not being considered “gainfully employed.” Consequently, despite the insurer continuing to deduct premiums during periods of temporary unemployment, this strict policy definition unfairly traps individuals like Anna, leaving them without the coverage they rightfully deserved.
The insurer’s initial decision to consider denying Anna’s claim was based on confirmation from her employer’s Human Resources department that she was physically present on the final day of her contract. However, this overlooked the broader context: Anna was not performing her substantive duties that day; she was merely returning company property. Her health condition had made it impossible for her to continue working, and had her contract not been ending, she would not have come into work at all. This oversight by the insurer risked an unjust claim denial, undermining the very purpose of income protection insurance—to support individuals in their time of need. It also highlighted how employer flexibility, intended to support dedicated employees, can unintentionally disadvantage claimants. Insurers often rely solely on official sick leave records and fail to consider informal, off-the-record flexibility provided by employers.
We recommend that team leaders and managers document such flexible arrangements, especially when they are made due to illness or injury, to ensure they can be used as evidence if needed in the future – which had fortunately occurred in Anna’s case. We also urge Claims Assessors to seek more detailed insights from claimants’ direct line managers regarding duties, actual restrictions, and the ability to perform these tasks, rather than relying solely on information provided by Human Resources, which often lacks this context and is based primarily on payroll records.
Simplify My Claim’s Intervention
Recognising these issues, Simplify My Claim took decisive action. We highlighted the importance of considering Anna’s full medical history, her employer’s flexibility, and the overwhelming evidence that she was unfit for work before her contract ended. By bringing these factors to the insurer’s attention, we prompted them to seek additional information from Anna’s direct line manager, who had deeper insight into the flexibility being provided and Anna’s struggles. More so than what the Human Resources department had who were purely looking at pay records.
Although the insurer eventually recognised Anna’s legitimate claim, they introduced further delays by insisting on obtaining 12 months of payslips before seeking approval from their reinsurer. For a full-time employee with consistent salary details, this requirement was both unnecessary and burdensome—an internal process that only prolonged an already stressful situation. We urged the insurer to expedite the process using the salary information already provided by the employer, stressing that securing an indicative decision was crucial for Anna. Since the payment amount was known and wouldn’t change, we argued that the insurer and reinsurer could handle the detailed documentation after confirming a positive outcome, prioritising Anna’s need for certainty. This experience highlights the need for insurers to reconsider the necessity of collecting extensive payslips from full-time employees with stable salaries. Providing 26 fortnightly payslips, which many may not have readily available, to prove consistent salary is in our opinion excessive.
The Emotional Toll of the Claims Process
Throughout this process, there were numerous moments when Anna considered withdrawing her claim altogether, overwhelmed by the feeling that the insurer doubted the legitimacy of her situation. The stress and frustration were so intense that she nearly gave up on what was rightfully hers. This is not how the claims process should make anyone feel. It’s unjust for a system designed to protect individuals to instead push them to the brink of abandoning their claims. Without the unwavering support and guidance of Simplify My Claim, Anna advised that she would likely have walked away, losing the benefits she was entitled to during one of the most challenging times of her life.
The Crucial Role of Advocacy in Insurance Claims
Despite our repeated warnings about Anna’s vulnerability and the emotional toll of the prolonged claims process, these concerns were largely overlooked as the insurer prioritised its procedural and policy requirements. This situation highlights the essential need for advocacy in navigating insurance claims—advocacy that provides not only expertise but also empathetic and personalised support for customers.
We recognise that not every customer needs an advocate, but for those who do, it is crucial that this service is available. Providing essential claims support helps customers navigate the complexities of the process and ensures they receive the assistance they deserve.
Putting People First: The Human Side of Claims
Anna’s story serves as a stark reminder of the importance of looking beyond the surface when assessing insurance claims. It’s not just about ticking boxes and following protocols; it’s about understanding the human experience behind each claim and ensuring that the purpose of insurance is upheld.
At Simplify My Claim, we are committed to standing by our customer’s, advocating for their rights, and ensuring they receive the support they deserve. Because when it comes to insurance, it’s not just about policies and procedures—it’s about people.
If you’re facing challenges with an insurance claim or need assistance navigating the complexities of the claims process, don’t hesitate to reach out to us. Reach out to Simplify My Claim today to discover how we can simplify your claim journey with the support, expertise, personalised service, and empathy you deserve. Your peace of mind and well-being are our top priorities.