Life and disability claims

Transcription

1 THE CHARTERED INSURANCE INSTITUTE Life and disability claims Objective: To develop in the candidate: a knowledge and appreciation of the claim considerations for life and disability and critical illness insurance; a knowledge of the legal, medical and financial factors; the ability to apply knowledge and skills to practical situations; the ability to synthesise different aspects of the syllabus and apply them to given scenarios. 556 Notes: The syllabus will be based on English law and practice. The April session will test the legal position as of 31st August of the preceding year. The October session will test the legal position as of 28th February of the same year. 1. Introduction to claims management 1.1 Role of the claims department describe the role of the claims department. 1.2 Claims philosophy explain the claims philosophy of a life office, including the approach to: customer service; early intervention; claimant expectation. 1.3 Product control cycle and risk management discuss the product control cycle; discuss the principles of risk management. 1.4 Major benefit types discuss the major benefit types, including: income protection/mortgage protection and waiver of premium; critical illness; terminal illness and permanent total disability; death; describe the other benefit types, including: long-term care; hospital cash; accident. 1.5 Group and individual business explain the differences of approach between group and individual claims. 1.6 File management explain the importance of file management and the implications of poor file management. 2. Initial claim considerations 2.1 Policy in force determine whether a policy is in force; discuss the procedure in respect of a lapsed/paid up policy; discuss the procedure and explain the implications in respect of a lost policy; describe the procedure in respect of proof of age. 2.2 Underwriting discuss the importance of reviewing the proposal form and underwriting papers; discuss the principles of underwriting. 3. Claims assessment tools what is available and when to use them 3.1 Communication explain the importance of effective briefing and questioning communication used in the claims handling process. 3.2 Medical reports, notes and examinations describe the use and purpose of GP reports and notes; consultant reports; independent medical examinations; functional assessments; vocational assessments of 5

2 3.3 Claims forms, questionnaires and other evidence explain the use and purpose of occupational questionnaires and job descriptions; explain the use and purpose of financial questionnaires and other financial evidence; explain the importance and use of claim forms. 3.4 Private investigators explain the use and purpose of private investigators; explain the legal and industry guidelines for the use of private investigators. 3.5 Home and employer visits explain the use and purpose of home and/or employer visits in the handling of life and disability claims. 3.6 Occupational therapists explain the role of occupational therapists in life and disability claims assessment. 3.7 Proof of death explain the procedures and documentation required for death claims; explain the role and procedures of the coroner. 3.8 Sources of information explain how other sources of information such as the internet, Companies House and the ABI register are used to assist with life and disability claims processing. 4. Financial assessment 4.1 Financial underwriting describe the financial underwriting considerations applicable to the following types of claim: income protection; critical illness; total permanent disability; death. 4.2 Limitation of benefit assess the application and implications of limitation of benefit, particularly in relation to: income/mortgage protection; key person/locum cover; group income protection benefits. 4.3 Employment types evaluate the importance of the following forms of employment and the evidence required for claims assessment: employed; self employed; employed directors; partnerships; combined business structures; personal service providers; policyholder/spouse who run their own business. 4.4 Other financial considerations discuss the purpose, nature and effect of other financial considerations, including: benefits in kind; dividends; commission; depreciation; drawings; pension. 4.5 State Benefit system describe the State Benefit system and in particular: available Benefits; assessment and entitlement to those Benefits. 4.6 Proportionate and rehabilitation benefits discuss the purpose, nature and application of proportionate and rehabilitation benefits. 5. Determining validity of the claim 5.1 Claim policy conditions assess the nature and application of standard claim policy conditions for each benefit type, including exclusions. 5.2 The role of experts describe the role and use of experts in life and disability claim handling, including: chief medical officers; solicitors; accountants. 5.3 Review procedures for income protection claims and waiver of premium discuss the review procedures for regular payment claims and waiver of premium. 5.4 Group claims discuss the issues posed by the following for group claims: actively at work; switched schemes; pre-existing conditions; eligibility; termination of employment; free cover; death in service; scheme salary; rights of third parties of 5

3 5.5 Critical illness, terminal illness and permanent total disablement assess the issues in relation to the interpretation of definitions for critical illness, terminal illness and permanent total disablement claims. 5.6 Determining title assess the issues affecting the determination of title, including: death; assignment; trusts; power of attorney; Court of Protection orders; bankruptcy. 5.7 Overseas claims discuss the issues applicable to overseas claims. 5.8 Non-contractual provisions discuss the operation and implications of the non-contractual provisions, including: commuted values; ex-gratia payments; provisional/on account. 5.9 Non-disclosure discuss the identification of non-disclosure in relation to a claim; discuss the evidence required to investigate suspected non-disclosure Declining claims discuss the recommended procedures for declining claims and the implications thereof. 6. Legal and regulatory issues at claim stage 6.1 Non-disclosure and misrepresentation explain the classifications of non-disclosure and misrepresentation; assess the remedies for each. 6.2 Determining and responding to fraud discuss the methods for determining and responding to fraud, including fraud conditions. 6.3 Utmost good faith discuss the application of utmost good faith to life and disability claims, including: duty at proposal; duty at commencement/reinstatement; duty at claim stage. 6.4 Legislation outline the main provisions of the following pieces of legislation and their application to life and disability claims: Financial Services and Markets Act 2000; Contract Rights of Third Parties Act 1999; Human Rights Act 1998; Data Protection Act 1998; Protection from Harassment Act 1997; Disability Discrimination Act 1995; Unfair Terms in Consumer Contract Regulations 1994; The Access to Health Records Act 1990; Unfair Contract Terms Act 1977; Proceeds of Crime Act 2002; Life Assurance Act 1774; Access to Medical Reports Act 1988; Current money laundering regulations. 6.5 ABI Codes of Practice and the FSA ICOB Rules evaluate the role and impact of the ABI Codes of Practice and the FSA Insurance Conduct of Business Rules on life and disability claims. 6.6 Agency describe the implications of use of agency and the role of the agents in life and disability claims. 6.7 Dispute resolution describe the appeals process in relation to a claim, including the FSA complaint handling rules; explain the role and procedures of the Financial Ombudsman Service, and discuss how strict law is modified; describe the Woolf reforms and the impact on dispute resolution; discuss the use of contractual and other types of arbitration. 7. Actuarial considerations and reassurance 7.1 Actuarial aspects outline the actuarial aspects of life and disability claims, including: inception and termination rates; experience analysis; commuted values; claims reserves; actuarial control cycle. 7.2 Reassurer and reassurance describe the role of the reassurer and the types of reassurance available of 5

4 8. Disability terms and concepts 8.1 Definition of terms describe the differences between the following terms: disability; incapacity; functional capacity; impairment; handicap. 8.2 Models of disability describe the definition of different models of disability. 9. Disability assessment 9.1 Factors to consider evaluate the impact of the following factors in relation to disability claims assessment; medical conditions, mental and physical; occupation; social factors; motivation; functional limitations; financial considerations. 10 Medical aspects of claims assessment 10.1 General considerations and product specific details discuss general medical considerations in respect of claims assessment, including: musculo-skeletal problems; respiratory diseases; cancer; neurological disease and injuries; sensory disabilities vision and hearing; mental health problems; cardiovascular diseases; renal problems Subjective and variable conditions discuss the assessment of subjective and variable conditions Multiple impairments discuss the implications of multiple impairments. 11. Rehabilitation 11.1 Assessment of skills describe the assessment of social and communication skills; discuss the assessment for return to work; describe the assessment and guidance for non-work activities; describe the possible outcomes and alternatives to previous employment Rehabilitation discuss the principles of rehabilitation and their relevance to claims assessment; discuss the process of rehabilitation including early intervention; explain how the outcomes of rehabilitation are evaluated; describe the personal and social aspects of rehabilitation Rehabilitation agencies and specialists explain the role of other agencies, medical specialists and the Department for Work and Pensions. Reading list The following list provides details of various publications which may assist with your studies. The primary text for this syllabus is shown in bold type. Periodicals and publications listed as additional reading will be of value in ensuring candidates keep up to date with developments and in providing a wider coverage of syllabus topics. Any reference materials cited are authoritative, detailed works which should be used selectively as and when required. Note: The examination will test the syllabus alone. The reading list is provided for guidance only and is not in itself the subject of the examination. CII/Personal Finance Society members can borrow most of these additional study materials from CII Knowledge Services and may be able to purchase some at a special discount. For further information on lending and discounts go to Primary text Life and disability claims. London: The CII. Coursebook 556. Additional reading Guide to life assurance underwriting. Keith Sankey. 3rd ed. London: Buckley Press, Distributed by Incisive Financial Media. Recent developments in life assurance law. Robert Surridge. London: CII Knowledge Services. Updated as necessary. Available online at (CII/Personal Finance Society members only). The regulation of long-term insurance and investment business. Tony Wiltshire. London: CII Knowledge Services. Updated as necessary. Available online at (CII/Personal Finance Society members only). Utmost good faith and non-disclosure. Ian Youngman. London: CII Knowledge Services. Updated as necessary. Available online at (CII/Personal Finance Society members only). Reference materials Brackenridge s Medical selection of life risks. 5 th ed. Editors, R D C Brackenridge, Richard S Croxson, Ross Mackenzie. London: Palgrave Macmillan, Dictionary of insurance. C Bennett. London: Pearson Education, Also available online at (CII/Personal Finance Society members only). Law of life assurance. Houseman and Davies. 12th ed. London: Butterworths, New ed expected 2007, published by Tottel. Life assurance contracts. Andrew McGee. Abingdon (Oxfordshire): Routledge-Cavendish, MacGillivray on insurance law: relating to all risks other than marine. 10th ed. London: Sweet & Maxwell, of 5

5 Periodicals Cover. London: Incisive Financial Publishing. Monthly. Health Insurance & Protection. London: Informa. Monthly. The Journal. London: The CII. Six issues a year. Also available online (CII/Personal Finance Society members only) at Post Magazine. London: Incisive Financial Publishing. Weekly. Professional Pointers. London: Faculty of Life and Pensions. Several issues a year. ed regularly to faculty members and available online at (CII/PFS members only). Websites CII Knowledge Services Examination guides You are strongly advised to study these before the examination. Please visit to buy online or contact CII Customer Service for further information on +44 (0) Exam technique/study skills There are many modestly priced guides available in bookshops. You should choose one which suits your requirements. You will also find advice at (CII/Personal Finance Society members only). For a more interactive approach, you should consider: Winning the brain game. London: The CII, CD-ROM of 5