What do “total disability” and “total incapacity” mean?
The term “total disability” means that the consumer has to be totally unable to carry out their occupation, before benefits can be paid under their income protection policy. This is also sometimes referred to as “total incapacity”. We take the view that the words “total” or “totally” are a very strict test in this context. This means the focus of our investigation in a case like this is on whether the consumer is totally unable to carry out the essential or substantial duties of their occupation – not on whether they are totally... Lire la suite
What type of evidence do I need, to back up my complaint?
The best evidence is medical evidence from the consumer’s own treating consultant (or other specialist involved in their care) – where the specialist comments on the consumer’s condition at the dates relevant to the claim. Other medical evidence could come from the consumer’s GP, an occupational physician or an independent specialist. It is helpful if a doctor or specialist can give an opinion on how any condition prevents the consumer from working in their existing occupation or in any other role. We will look at this evidence carefully,... Lire la suite
What if the definition of “total disability” wasn’t explained when I took out the policy?
If a consumer complains that the way the insurance cover worked wasn’t adequately explained to them when they applied for the policy, we will ask them for information or evidence as to what they were told at the point of sale – and what information was provided when they agreed to purchase the policy. For example, defining disability as being incapable of carrying out “any occupation whatsoever” – a definition which sometimes appears in this type of insurance policy – is a very strict test. So we say that someone who sold a policy like... Lire la suite
Are insurance companies allowed to review a claim they’re already paying – and stop benefits?
Insurance companies have the right to review claims from time to time, to make sure that consumers claiming benefits continue to meet the terms of the policy. But before an insurance company stops paying a claim, it should explain clearly why it believes that the consumer’s condition has improved – to the extent that they no longer meet the definition of “total disability”. The insurance company may seek updated medical opinion, or ask the consumer to attend a medical examination. It may also ask the consumer to complete a “continuing... Lire la suite
What if I’m unhappy with my insurance company’s decision to reject or stop my claim?
You should first raise your complaint directly with the insurance company – and give them the opportunity to review your case. By law it has to investigate your complaint thoroughly – and it has up to eight weeks to do this. If you are unhappy with your insurance company’s explanation at this stage, we may then be able to get involved. We will ask you to complete our complaint form with your details. If you are complaining about your claim being rejected, without any benefit paid to you, you will need to provide us with the medical evidence... Lire la suite
