Being outside the policy terms or definitions
This means that a claim is made on something that is not actually covered in the customer’s policy, so naturally we can’t pay these claims.
Two things you can do to be confident about what you’re covered for:
- Be certain about what you’re covered for,
- Speak to your adviser to ensure you’re adequately covered for your needs.
Not complying with your duty to take reasonable care not to make a misrepresentation
When taking out a policy the person being insured has a legal duty to take reasonable care not to make a misrepresentation to the insurer before the contract of insurance is entered into. Not complying with this duty means that an answer in the application may have been false or misleading, only partially true, or an answer does not fairly reflect the truth. There may be circumstances where we later investigate whether the information given to us was true. For example, we may do this when a claim is made.
Some examples could include things like a history of medical issues or an occurrence of specific illnesses or injuries, or inaccuracies in occupational or financial details. Some misrepresentations have a limited impact on underwriting, while others are more significant. Not all misrepresentations are equal, and they’re assessed differently at claim depending on the customer’s circumstances.
Learn more about how our claims team makes decisions and supports claimants in their time of need.
This means that a claim is made on an event which has been specifically excluded from the customer’s policy.
For example, if a customer came to us seeking to be protected with Income Secure cover and has a pre-existing condition like depression, we may agree to cover the customer for all events except for those related to their condition and include a premium loading. This 12% of claims are declined because a customer is claiming on an event which is not covered in their individual policy
Check your Policy Schedule for details on policy exclusions related to your policy (the schedule is attached to your Welcome or Renewal letters).
We want to pay all genuine claims.
Unfortunately, sometimes we discover that some claimants mislead us to get paid out when they don’t have a legitimate reason to be. In the best interest of all our customers, we firmly decline these claims.