Case Study – Interpreting the Policy Intent (Example 2)

In this claims case study, the claimant was denied a TPD payment as her specialist did not believe she would be unable to work again. The dealer group was able to negotiate an overturn of the insurer’s original decision to decline the claim by contacting an alternative medical specialist. It demonstrates the importance of building strong relationships between advisers, dealer group management and claims managers.

At a glance

Submitted by: Tony Lye
Company: Aon Financial Planning & Protection
Claimant: Female, diagnosed with lupus
Claim type: TPD

In detail

The client contracted the autoimmune disease of lupus.  This disease has the effect of attacking healthy cells and structures in the body, which can cause inflammation, damage and pain.  Despite years of research, the cause of lupus is still unknown.

While the client’s local GP said she should not work again, a specialist in the field was not prepared to state that the client was unlikely ever to be able to work again.  Her TPD claim was dismissed.

Aon approached the insurer and all parties agreed to abide by the decision from another specialist who was asked to provide a further opinion on the client’s case.

the impact on the client and her family of the decision to accept the claim was life changing

As the client’s bank was in the process of foreclosing on her home for her inability to repay her mortgage, the specialist returned with an opinion that, given her condition, the client was indeed unlikely ever to return to work.  Based on this further opinion, the insurer reversed its decision and admitted the claim.

According to Mr Lye, the impact on the client and her family of the decision to accept the claim was life changing: “She received $1.7m which settled her mortgage and secured the financial future for herself and her three young children.  The client advocacy program turned around the lives of a family that one day was going to lose their home, had no income and a bleak future, to a family with no debt and over $1m in the bank,” said Mr Lye.

There are more detailed elements involved in this case than the brief summary above, where the insurer could have presented a valid case for denying the claim by applying a literal interpretation of the policy wordings. Both Mr Lye and Managing Director of Aon Hewitt Wealth Management, Pierre Kraft, have given credit to the insurer for their goodwill in reassessing this and other denied claims in the spirit in which the original policy was intended to protect the client in their time of need.

For another example of how Aon’s client advocacy process worked in favour of a claimant, see also: Interpreting the Policy Intent (Example 1).

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