How to make an income protection claim

How to make an
income protection claim
How to make an income protection claim
If you become ill or have an accident you may not be able to
work. An income protection plan helps you to make sure you can
provide for yourself and your family.
This document tells you what you need to do and what we will do
if you make a claim. You should read this document carefully and
then keep it safe for future reference.
Our aim is to handle claims quickly, fairly and efficiently with
minimum inconvenience to you. As a mutual society we believe it
is our duty to fully assess all claims and make the fairest
judgement possible.
Definitions
In this document we use words and phrases that not everyone will
be familiar with. We’ve explained what these mean below.
• Claims visitor – a qualified nurse who is fully trained in our
claims process and will visit you in your home.
• Deferred period – the period that you wait before you start
receiving benefit payments. You chose the deferred period
before your plan started, and this is shown in the schedule.
• Essential duties – are those duties which cannot be left out
(omitted) without affecting your ability to carry out your normal
occupation.
• Incapacity – this is defined in your policy terms and conditions.
Usually, by incapacity, we mean that you are totally unable to
carry out the essential duties of your normal occupation
because you’re ill or have had an accident and you are not
doing any other work. (Your normal occupation is shown in the
schedule.)
• Normal occupation – your occupation which is shown in the
schedule.
Questions and answers
When can I make a claim?
• You should tell us about a claim as soon as possible. Each plan
has a formal notice period, which will depend on the deferred
period, which is shown in your policy schedule.
• If the deferred period is four weeks or less then you must tell
us within two weeks of when you were first unable to work. If
the deferred period is more than four weeks you must tell us
within eight weeks of when you were first unable to work.
• These formal notice periods give us time to collect any medical
reports or financial evidence that we need. However, you
should let us know as soon as possible so we can assess your
claim more quickly.
• You should claim if you are unable to carry out the essential
duties of your normal occupation because you are ill or you’ve
had an accident, resulting in a loss of earnings.
Does my income protection plan cover my ability to work at a
specific location?
• No, we provide cover if you are unable to work in your normal
occupation because you’re ill or have an accident, rather than
the availability of a suitable position.
Who should I contact?
• To make a claim call us on 0845 351 2352 and we will send
you the information you need in order for us to process the
claim.
How quickly will you process my claim?
• The more information you give us when you make the claim,
the quicker the process should be. If we can’t process your
claim straight away, we will contact you within three working
days and let you know what additional information we need.
Do you arrange a claims visit?
• In some cases we may arrange a claims visit to get the best
possible understanding of your circumstances. We will write to
you if a visit is required.
• If you expect to be off work for a long time we may ask a claims
visitor to visit you as soon as possible.
• The claims visitor will contact you to arrange a mutually
convenient time for them to visit you in your home.
• The claims visitor can help you complete the claim form, and
offer support and advice.
What medical information do you need?
• If you are unable to work for a short period of time then we will
usually only need information from your GP.
• If you can’t work for a longer period of time, we may also need
a specialist medical report as well as information from your GP.
If you have any reports prepared by a specialist you should
send them with the claim form, which may help speed up the
claims process.
• We will pay the costs if we need a more detailed report from
the specialist.
• We won’t accept a report prepared by your husband, wife or
civil partner.
If you accept my claim and agree to pay the full sum assured,
how do you calculate the benefit I receive?
How do you assess the medical information?
• Your claim will be assessed by our claims team, with support
from our team of Chief Medical Officers. They are:
− Professor Femi Oyebode MBBS, MD, PhD, FRCPsych
− Dr Rosalind Anfilogoff MRCP; and
− Dr Nic Anfilogoff MRCP.
Will I need an independent medical assessment?
• Sometimes our Chief Medical Officers might feel that an
independent medical assessment, from a specialist who is not
involved with your care, would help them to make a more
informed assessment.
• The assessment will be arranged at a convenient time and
location.
• We will pay the cost of this assessment and your reasonable
travelling expenses.
• We will let you know the outcome of the assessment as soon as
possible.
Do you share information with the insurers of my other income
protection plans?
• We may share information with your other insurers if you give
us your permission. This is to make sure we fully understand
your situation and make consistent decisions, although the plan
conditions may affect the decision. This can also mean your
claim is processed quicker because you don’t need to attend
medical examinations for each insurer.
Will the granting of ill-health retirement pension be accepted as
evidence of incapacity?
• No, we will not accept the granting of ill-health retirement as
evidence of you being permanently unable to work. This is
because someone who makes a claim can be granted ill-health
retirement and then return to work.
• If we accept your claim, we will only pay benefit while you
remain unable to work because of an ongoing illness. This is
very different from a pension, which continues to be paid
without any ongoing assessment of your health.
What happens if you accept my claim?
• We will write to you to let you know if your claim has been
accepted.
• We will start to pay benefit at the end of your deferred period.
For example:
− if you have a deferred period of four weeks, then no benefit
would be paid to you for the first four weeks of incapacity;
− if you have a deferred period of ‘0’ weeks then we will only
start to pay benefit after you have been unable to work for
seven consecutive days.
• After the deferred period, we will issue a cheque or a BACS
payment, depending on the payment method you choose.
• We will continue to pay benefit for as long as your
circumstances stay the same. If your claim continues for a long
time we will need to update medical and financial evidence
from time to time. The details of the reviews will depend on
your individual circumstances. We will let you or your doctors
know what evidence we need.
• We pay benefit each month in arrears and calculate the
monthly payment as follows:
Sum assured
–––––––––––––– x number of days in the month
7
• If the payment period is less than a full month then it is
calculated as follows:
Sum assured
–––––––––––––– x number of days in the payment period
7
• If we can’t pay the full sum assured we will send you a detailed
explanation why.
What evidence of my earnings do you need?
• If you are an employee we will need a copy of your latest P60,
and copies of three pay advice slips from immediately before
you were first unable to work.
• If you are self-employed or in a partnership we will need a copy
of your latest profit and loss accounts, and your latest tax
return.
Do I have to pay premiums whilst I am claiming?
• The waiver terms depend on your deferred period.
• If we accept a claim and the deferred period is 13 weeks or
more, we will waive your premiums after the deferred period
has ended.
• If we accept a claim and the deferred period is less than 13
weeks, we will waive your premiums 13 weeks after you have
been incapacitated.
• We will calculate whether waiver of premium has been over or
under paid at the end of the claim.
Will a claim affect my premiums?
• No, we review our premiums based on the level of claims being
paid to all plan holders, not on an individual basis. A change to
your premium will relate to our total claims experience, rather
than your personal claims history.
• Premiums under a unit-linked plan may also be affected by
investment performance.
• Some policies are not reviewable, which means they will not be
affected by any claims. These are mainly those arranged before
December 1990. For more information please refer to your
policy conditions for details or contact us.
Will you continue to review my claim after you accept it?
• Yes, we will review all cases each year, or more often in some
cases, to check if there have been any changes in your
circumstances.
• The details of the reviews will depend on your individual
circumstances. We will let you or your doctors know what
evidence we need. We may need more medical information,
arrange a claims visit, ask you to have an independent
assessment, ask you to make a declaration or request more
current financial evidence.
Can I go back to work part-time and still receive benefit?
• It is in everyone’s best interest for you to return to work if you
are well enough to do so.
• If you have not been able to work for at least 13 consecutive
weeks, or the deferred period (if longer), and we have paid you
some benefit for this absence, we will pay you a reduced
benefit if you go back to your normal occupation part-time (less
than 30 hours a week). This is called rehabilitation benefit and
has been included in our protection plans since 1981.
• We will stop paying rehabilitation benefit if:
− your income from part-time work is equal to or more than
your income before incapacity; or
− you are able to carry out the essential duties of your normal
occupation for more than 30 hours a week.
• To assess the correct levels of rehabilitation benefit, we will
need the details of the hours you worked each week to be
presented monthly and we may need confirmation of your
earnings for the period.
What happens if I get better but can’t return to my normal
occupation and I take up another job?
• If you recover from the illness or accident but are not fit enough
to go back to work in your normal occupation, we will pay you a
reduced benefit if you take up a different occupation. This is
called proportionate benefit.
• We will stop paying proportionate benefit if:
− your income from your new occupation is equal to or more
than your income before incapacity; or
− you return to your normal occupation, as stated in the
schedule.
• Your benefit will depend on how much less you earn in the new
occupation. For example, if you earn £10,000 a year in your
new occupation compared with £30,000 in your normal
occupation, you will be entitled to a maximum of two thirds of
your benefit.
Are there any circumstances when you might make a payment
outside of the cover provided by the plan?
• Yes. We recognise the long-term benefit of helping you get
back to work, and there are occasions where we will make
payments outside of your cover. We have done this in the past
to fund private treatment, rehabilitation counselling and help
during retraining.
When will you stop paying my claim?
• The benefit will be paid until the first of the following happens.
− Medical evidence proves you are capable of performing the
essential duties of your normal occupation.
− The plan ends.
− You die.
− You no longer suffer a loss of earnings.
• We might also end your plan if:
− you keep relevant information from us, mislead us by giving
us incorrect information or fail to tell us of any change in your
circumstances; or
− you have recovered after a claim, then exaggerated your
symptoms to continue receiving benefit. If we allowed these
claims to continue it would increase future premiums for
other customers. If we suspect this to be the case your claim
will be reassessed by at least one of our Chief Medical
Officers, we will review the recommendation and then make
a final decision about your claim.
What happens if you decide I am no longer entitled to benefit?
• In most cases we will give you at least one month’s notice if we
are going to stop your benefit. You may need to be retrained for
work or find a new position, so we may offer a reduced
payment over a longer period.
• If we stop your benefit because you have withheld relevant
information, misled us or not told us of changes in your
circumstances, we will stop payments immediately.
Do you use private investigators to check if someone is still
unable to work?
• In some cases, it is necessary for insurers to hire investigators
to make enquiries about someone who is receiving benefit.
• Investigations can include video evidence but we only use
reputable firms and make sure they operate in a way that
complies with the independent ombudsman service.
• We only use investigators where we have good reason to
suspect a fraudulent claim, or where someone is materially
exaggerating their condition. Surveillance is carefully
considered before it is used.
• As a mutual society, it is our duty to look after our customers’
best interests. We will take action to make sure our customers
don’t suffer a rise in premiums because of fraudulent or
exaggerated cases.
• We believe that it is right as part of a mutual society to take
such actions in the interests of all our customers, as it is unfair
if premiums have to rise because of such claims.
What can I do if I am unhappy with the way my claim is
handled?
We hope that you’re happy with our service. If you do need to
complain about the way your claim is handled, please contact us
in one of the following ways:
• Call us on 0845 351 2352. Our lines are open from 8.30am to
6.30pm, Monday to Friday and from 9am to 2pm on Saturdays.
We may monitor our calls to improve our service.
• Write to us at:
The Complaints Team
Compliance Department
Wesleyan Assurance Society
Colmore Circus
Birmingham B4 6AR
If you write to us, we will acknowledge your complaint and send
you a copy of our internal complaints procedure within five
working days.
• Fax us on 0121 200 2971.
• Visit our website at www.wesleyan.co.uk.
Your complaint will be thoroughly investigated by someone who
has not been directly involved in your case. We may need to
consult our Chief Medical Officers.
We will give you regular updates on the progress of your
complaint.
If we decide to uphold our original decision we will let you know
your rights to appeal to an independent ombudsman scheme,
together with any other helpful information we can provide.
If, after receiving our response, you’re still not happy, you can
complain to the Financial Ombudsman Service.
• The Financial Ombudsman Service
South Quay Plaza
183 Marsh Wall
London
E14 9SR
• Phone: 0800 023 4567 (free if you are calling from a landline)
• Phone: 0300 123 9 123 (free if you are calling from a mobile
phone and you pay a monthly charge for calls to numbers
starting 01 or 02)
• Email: [email protected]
• Website: www.financial-ombudsman.org.uk
If you complain to the ombudsman, it won’t affect your legal rights.
We hope that you have found this document useful. However, this
is only a guide to answer the most frequently asked questions.
For full details of your plan conditions please read your plan
document.
For all your financial needs:
•
•
•
•
Savings and Investments
Retirement Planning
Life and Income Protection
Mortgages and Insurance
Please call: 0845 351 2352
Or visit: www.wesleyan.co.uk
If you would like this document in Braille, large print
or audio tape, please contact 0845 351 2352.
Head Office
Wesleyan Assurance Society
Colmore Circus
Birmingham B4 6AR
Advice is provided by Wesleyan Financial Services Ltd through its brand names including
Wesleyan Medical Sickness, Wesleyan for Teachers and Wesleyan for Lawyers.
Wesleyan Financial Services Ltd is wholly owned by Wesleyan Assurance Society. Wesleyan Assurance Society is authorised
and regulated by the Financial Services Authority. Incorporated by Private Act of Parliament (No. ZC145).
Fax: 0121 200 2971. Telephone calls may be recorded for monitoring and training purposes.
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