Putting the pieces together in the puzzle of life insurance claims

The stress experienced post trauma and or during ill health is significant, often made worse by not being able to work for a period of time. When costs mount and cash dwindles, this stress can become unbearable; hence the need for insurance to assist in supporting and carrying one through these circumstances.

At least, that is the general perception of the promise and assurance sold by insurance companies at the time of taking out illness or injury related cover.

The reality however, is that this promise may take time to be met, and on some occasions may not be met at all when a claim is lodged.

Whilst some claims simply do not meet the necessary contractual terms, which leads to their rightful declinature, many do – but only after a lengthy process.  A process during which the individual experiencing ill-health may have had to ‘jump through’ different and time-consuming ‘hoops’, alongside arguing their case in order to comply with the requirements of the selected insurer.  In other words, prospective claimants need to prove the insurer’s liability.

Although an insurer is perfectly entitled to carry out as thorough an investigation as it deems fit prior to making a claims decision, the exacerbation of stress and the prolonging of ill-health that is often caused by the claims process is not necessarily a consideration that is fully appreciated by busy claims handlers. Furthermore, sometimes the claims decision made is plain wrong, possibly based on thin arguments and weakly formulated opinions.

There are a number of reasons why the ‘incorrect’ claims decision occurs, some of which are due to the limited or poor evidence provided, and some of which may be due to an insurer taking a specific view based on evidence seen through a specific paradigm. There are also the cases in which the infamous ‘hired gun’ has offered a view that may be less than fully objective in nature, but on which an insurer may have chosen to rely.

The bottom line is that, far too often, a protracted claims assessment period and or an unsuitable decision for the life concerned results in unnecessary anxiety, fear, loss of income, frustration, depression and a sense by the life assured that the chosen insurer does not care.  Nobody wins.

Due to the extensive experience in this field, along with managing numerous independent disputed claims referrals per annum, Burns-Hoffman Consulting has teamed up with LLA Inc. Attorneys in developing a new and easily accessible independent service that gives access to lives assured to deal with their contractual disability, incapacity and ill-health claims in a timeous and cost effective manner.

The service provides both expert contractual assessment and opinion on the probable merit of the above-mentioned types of claims, as well as legal representation when required in objectively presenting such merit to the life office concerned.

This service, which is immediately available to clients who need it, enables those who do not have the funds to pay for legal representation to enter into a no-win, no-fee arrangement with LLA Inc., and Burns-Hoffman Consulting acts as an independent advisor to LLA Inc. in the provision of claims specific analysis and opinion.

The independent opinion service, already provided by Burns-Hoffman Consulting and used by lives assured, financial advisors, corporates and life insurers, is simply not affordable to many individuals who seek this kind of professional guidance and support. Working with LLA Inc. however, makes it more accessible to those who have legitimate disputes, but are limited in their access thereto due to a lack of funds.

Although anyone with a life insurance complaint always has the facility of the office of the Ombudsman for Long-Term Insurance available when questioning claims decisions, this office’s preferred approach to matters is usually one of inviting engagement and discussion with insurers prior to finalisation, rather than moving to a quick determination, which can take longer than is ideal in certain situations.

Given the different market needs, LLA Inc. and Burns-Hoffman Consulting have identified that there is a client base that seeks a different approach, and have stepped in to fill this particular space.

The practical process adopted by LLA Inc. is to assess the merit of a referred claims matter for a small upfront fee, following which a decision is made with regard to the probable validity – or not – of a claim. Only cases where there is deemed to be probable merit based on the evidence in hand will be pursued on the basis of a no-win,-no-fee basis.  Cases determined to be lacking in merit will not be pursued. 

Matters can be referred directly to Ms Romany Sutherland, Attorney and Mediator at LLA Inc. via romany@llalaw.co.za or on(021) 554 2135.

For more information on Romany and Elise please visit www.llalaw.co.za and www.b-h.co.za

ELISE