Helen’s joint disease claim

It's important to know what you're covered for

Trauma cover provides protection against many serious medical conditions. But when Helen was diagnosed with Spondyloarthropathy, a joint disease of the vertebral column, she unfortunately wasn't eligible to make a claim.

Helen's trauma cover claim

Helen took out a trauma cover policy with OnePath in 2010 at the age of 31.

As a single parent of two young children, Helen wanted certainty that if something were to happen to her, she would be able to provide for her children.

What happened...

With the support of an adviser, Helen went through her insurance options and decided that Trauma Premier was the best cover for her needs. Together, they went through the details of her policy and submitted an application.

Four years later, Helen was diagnosed with Spondyloarthropathy – a joint disease of the vertebral column. She lodged a claim on her trauma policy in 2018, but while her policy covered her for many serious conditions, hers was not one of them. The assessors attempted to determine whether she qualified for Rheumatoid arthritis (a similar condition which was covered by the policy) but she did not meet the criteria to claim.

Our decision

Unfortunately, on this occasion, Helen’s claim was declined because her circumstances did not meet the terms for payment of her condition, or under the definition of Rheumatoid arthritis.

In informing Helen, the claims consultant Peter clearly explained the reason for the decision, listing the evidence Helen had provided to support her claim, explaining the conditions of her policy under which she was claiming, and inviting Helen to call him to explain the decision reached.

At OnePath, we’re in the business of paying claims that our customers are covered for, and it is our mission to be there for customers when they need us most. In fact, we pay over 93% of all lodged claims on advised policies.

However, it’s cases like Helen’s – defined by medical conditions that are outside of the terms of the policy – that are the main reason we end up declining around 7%.

For us at OnePath, to offer affordable protection to our customers, policies are priced based on a calculation of the future risks our customers face of suffering a set of clearly defined diseases and illnesses included in their policy. Although it would be our wish to cover customers for every risk they would ever face, this cannot be feasibly done. So taking out a policy means paying a regular premium to be covered for a set of diseases, illnesses and conditions set out in the terms of the policy.

At OnePath, we have the top-rated claims team in the country, and are proud to be there for our customers when they need us most.

Source: In 2022, OnePath paid 92% of lodged advised claims

Whilst the names have been changed to protect the individual claimant, this case study is based on the actual circumstances of the claimant. This is for illustrative purposes only, and claims will be assessed based on the specific circumstances of each individual case.

OneCare is issued by Zurich Australia Limited (Zurich) trading as OnePath Life (OneCare) ABN 92 000 010 195, AFSL 232510. OneCare Super is issued by OnePath Custodians Pty Limited (OnePath Custodians) ABN 12 008 508 496, AFSL 238346.  Zurich and OnePath Custodians are not related bodies corporate.

We recommend that you read the OneCare Product Disclosure Statement and Policy Terms available at www.onepath.com.au or by calling 133 667 before deciding whether to acquire, or to continue to hold the product.