A policyholder s guide to making a claim frequently asked questions We aim to make the claims process as straightforward as possible. This leaflet guides you through the process and answers some of the questions we are frequently asked. This leaflet may not answer all of your questions, as the individual circumstances of each claim will differ. If you have any further queries please get in touch with our claims team using the contact details at the end of this leaflet. How and when should we submit a claim? If it appears that the member s illness or injury will extend beyond the deferred period and you want to make a claim, you must submit: a fully completed, current claim form, signed by an official of the employer and signed by the member. when a member has been suffering incapacity for: four weeks, if the deferred period is 13 weeks, or 10 weeks, for any longer deferred period. We will not pay any benefit, or any additional amounts of benefit, if we receive either a completed claim form or a completed personal statement later than six months after the end of the deferred period. You should send completed forms and documentation to: IP Claims Management Services Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Fax: 01707 671100 E-mail: ipclaims@canadalife.co.uk Claim forms are available to download from our website www.canadalife.co.uk/group/insight-adviser-zone/makingaclaimgipadviserzone.asp or by contacting us at the above address. Leaflets providing further information are also available. If you have any questions regarding the completion of the form or the submission process, please call us on 0345 223 8000. 1
What happens if a member has had repeated absences as a result of the same incapacity? If a member is absent from work for short periods of time, with the same incapacity, these may be added together to calculate the deferred period. These absences must occur within a period that is no more than twice the length of the deferred period. For example: if your deferred period is 26 weeks and there have been several periods of absence which total 26 weeks, within a maximum of 52 weeks, these may be added together to produce the deferred period. What will happen next? When we have received all of the initial forms and information, we aim to tell you within five working days: what further information we need to assess the your claim, or whether we can consider your claim. If we cannot consider your claim we will tell you why not. If we can consider your claim, we will ask the member s General Practitioner and/or consultant(s) for details of medical history and the treatment being given for the incapacity. We may also: contact the member by telephone to obtain a fuller picture of their circumstances. ask a specialist to conduct an independent medical examination. ask a rehabilitation consultant to contact you or the member (see below). arrange for other investigations to be done. Our rehabilitation consultants are experienced nurses who deal with all aspects of Income Protection. They will usually contact the member to arrange a visit and will carry proof of identity. Whilst visits are arranged to help us assess your claim, the rehabilitation consultant is also trained to help you and the member by answering questions about Income Protection, State Benefits and Rehabilitation. How is a claim assessed? We will make an objective assessment of the nature of a member s incapacity including the severity of any medical condition, how long it has existed and what affect it has on the member. We will then seek to determine whether or not they would be able to undertake the tasks involved to satisfy the definition of incapacity, taking into account any adaptations which would assist them to work. We will need evidence that the member is continuing to receive medical advice when appropriate and that treatment options have been investigated and explained to them. We will also consider any medical reports or additional information that you or the member give us. We reserve the right to use any appropriate means to investigate your claim. We will arrange periodic medical reviews to confirm that the member s illness or injury continues to meet the definition of incapacity you have agreed with us. You must provide us with any documents and information we need to process your claim. A breach of certain commitments within the Policy will result in us rejecting your claim. Who pays for the medical evidence? Canada Life will pay for any medical evidence obtained in the UK that we ask for. However, if the member does not attend a medical examination at an agreed date and time, you may incur a cancellation fee. How long will it take to process my claim? We are unable to provide specific timescales, as to assess your claim we need reports and information from medical and other professionals, which may take some time to complete. However, we follow up all information requested and aim to keep you adequately informed. 2
How can rehabilitation help? As an employer, you can minimise the costs of incapacity and maximise the value that incapacitated employees bring to an organisation by ensuring that rehabilitation and reintegration programmes are implemented wherever appropriate. Can benefits be paid during rehabilitation? If a member participates in a rehabilitation back to work programme that is agreed between you, Canada Life and the member s General Practitioner, attending physician, consultant or other suitably qualified person who is providing treatment of the member s illness or injury, we will maintain that member s income benefit under the Policy unless they are also receiving: benefit from any other schemes or policies; and/or payments from an employer, which, together with the income benefit we provide exceeds the member s earnings immediately before the start of their incapacity. Rehabilitation programmes are for a maximum of 12 months. Members must participate and co-operate with them, to the best of their ability. Similarly, employers must facilitate and support a programme that is agreed for an incapacitated member. There must also be a reasonable expectation that the member will recover from their incapacity and return to their normal occupation. How can you help? Working conditions, physical features and other arrangements can often be adjusted so that an incapacitated person can continue to work. It is a requirement of the Equality Act 2010 that employers make adjustments to working conditions where it is reasonable to do so. Our definitions of incapacity assume that you will comply with the law. Our staff can work with you and your medical advisers to draw all this information together so that the claims process runs as smoothly as possible. Does Canada Life follow Department for Work and Pensions decisions? Since the Department for Work and Pensions use different criteria to assess claims, it is possible they may reach a different decision to us. How will benefits be paid? If your claim is accepted, benefits will be paid monthly in arrears. These should be treated as a trading receipt and paid to the member as a salary through your payroll system, subject to all normal deductions. We will make payments direct to your bank account. For how long will benefits be paid?? We will pay income benefit until the member either: stops suffering incapacity; or no longer suffers loss of earnings; or leaves the service of an employer, or dies; or reaches their cease age you have agreed with us; or reaches the end of their contract of employment; or has received the appropriate number of income benefit payments for the limited period chosen; or ceases to be based in the UK; or starts any form of employment without our agreement; or ceases to be a member. But please see section 1.6 of the Technical Guide (TGGIPSTD0914) for further information on the duration and extent of benefit payments; and section 7, if the member has been working abroad. 3
Will the benefit be adjusted once in payment? If a benefit escalation has been insured on your Policy, the benefit will increase annually at the rate agreed in your Policy. For Net Pay, Fully and Partially Integrated benefits, a member s entitlement to the employment and support allowance, work related activity component and support component will be determined at the end of the assessment phase. We will therefore recalculate the benefits at that time. Where State incapacity benefits are appropriate to a member these will be adjusted as necessary, in line with State provisions. Could a member s benefits be reduced? If the member is receiving any other income besides our monthly benefit and any State benefits, the amount of benefit we pay may be reduced. The scheme is designed to ensure that incapacitated members receive an income which is lower than they received whilst working and therefore have an incentive to return to work. Other income that will be taken into account includes: salary and any other payments being made by an employer; pensions and annuities, in this respect we will ignore any pension or annuity that was in payment prior to and continues after the commencement of the member s deferred period; a group or individual insurance policy giving rise to income benefits as a result of illness, injury or disablement; a mortgage protection policy; a loan or credit protection arrangement (including credit and store cards); an insurance premium waiver. Except for income in respect of salary or other payments being made by the employer, where the payment period in respect of such income would normally be less than two years (other than solely as a result of the member being within two years of the cease age), we will only offset such income if the total of that income, the scheme benefit and any income from other sources payable for two years or more, would exceed the member s pre-incapacity earnings. Will our claim be reviewed? The member must continue to satisfy the definition of incapacity in order for benefit payments to continue. We therefore undertake medical reviews periodically to establish the extent of a member s incapacity and whether they continue to satisfy the definition of incapacity. What happens if an incapacitated member returns to work? Full time: Please tell us immediately if the member makes a full time return to work, as benefits payments must cease. Part time: If a member s illness or injury means that they can work on a part-time basis or in a reduced capacity we may agree to pay an income benefit that is in proportion to the reduction in a member s earnings, with an allowance for inflation, but only when the Standard definition of incapacity applies. This is known as proportionate benefit. We will also consider a claim for partial incapacity even if a full claim has not been paid. 4
Can another claim be made for a member for a further incapacity? You can make a claim for a member who suffers a further incapacity after the benefit payments for a previous incapacity suffered by that member have stopped, providing that: the member has in the intervening period, been actively at work; and the further incapacity is not being treated as a linked claim; and you have not already received benefit for the whole of any limited period of benefit payment. The member will have to complete a new deferred period before any income benefit can be paid under the Policy. Where you have chosen to limit the benefit payment period, we will treat a further claim for an individual member as a new claim. Any benefits payable under this new claim can be paid for the whole of the chosen limited payment period. If you have chosen an employer s lump sum, it will be payable at the end of your chosen limited payment period for this new claim. Examples showing the treatment of deferred period and maximum payment period for a further period of incapacity where a limited payment period applies The examples are based on a scheme with a deferred period of 26 weeks and limited payment period of three years (36 months). First payment Return to Nature of New deferred Maximum payment period period work period incapacity period for further incapacity 12 months 6 months Same cause Nil 24 months 12 months 6 months Different cause 26 weeks 36 months 12 months 24 months Same cause 26 weeks 36 months 12 months 24 months Different cause 26 weeks 36 months 36 months No further income benefit is payable. You cannot make simultaneous claims for different incapacities suffered by the same member. What happens if an incapacitated member leaves our employment? If a member s employment with you ceases before the end of the deferred period, Canada Life has no liability to pay the claim, as they are no longer a member of your Income Protection Scheme. However, if a claim is being paid, please notify us before your decision is finalised. In some circumstances, we may be able to consider continuing the claim on a direct basis (where Canada Life deals directly with your employee). However, this will result in changes to the Terms and Conditions of the claim. 5
What happens if an incapacitated member s contract of employment is transferred to a different employer under a TUPE arrangement? When an incapacitated member (including an incapacitated member within a deferred period) transfers to a different employer under TUPE regulations, we will, subject to: the new employer taking responsibility for the member s potential rehabilitation as if it were the policyholder, the new employer adhering to its obligations under the Equality Act 2010; and, completion of all relevant documentation by you, us and the new employer, continue to pay any eligible income benefit (but not an employer s lump sum) to the new employer, treating such claim as if there had been no break in employment. What happens to claims if the Policy is discontinued? If the scheme ceases to be insured with us, provided all premiums due are paid up to date, we will: continue to pay benefits in respect of claims that were accepted before the scheme ceased, for so long as they remain valid consider claims where incapacity occurred before the scheme ceased, but have not been accepted before that date, for example because the deferred period has not been completed. If cover is continued immediately with another insurer, without a break in cover, for the same benefit and eligibility basis that applied immediately prior to the date cover ceased, the following will apply in respect of Linked Claims. If, on returning to work, the member: satisfies the new insurer s actively at work requirements, we will pay benefit for a Linked Claim for the whole of the deferred period under the new insurer s Policy. The new insurer will be responsible for the claim and any payment of benefits from the end of the deferred period does not satisfy the new insurer s actively at work requirements, we will pay the benefit and continue to be responsible for the claim. Who should we contact about our claim? We can be contacted at: IP Claims Management Services Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Tel: 0345 223 8000 Fax: 01707 671100 E-mail: ipclaims@canadalife.co.uk Website: www.canadalife.co.uk/group Our forms are available to download from our website: www.canadalife.co.uk/group Canada Life Limited, registered in England no. 973271. Registered Office: Canada Life Place, Potters Bar, Hertfordshire EN6 5BA. CLFIS (UK) Limited, registered in England no. 04356028 is an associate company of Canada Life Limited. Registered Office: Canada Life Place, Potters Bar, Hertfordshire EN6 5BA. Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. GRP395 315R Canada Life Limited 3 Rivergate, Temple Quay, Bristol BS1 6ER Telephone 0345 223 8000 6