How we assess claims
We recognise the distress that serious illness can cause for customers and their families, and every claim is assessed with care. With more than one million policyholders, we apply the same claims assessment standards consistently to ensure fairness for all customers. Claims are evaluated in accordance with the policy terms and conditions of the policyholder’s plan. Before buying an insurance plan, it’s important to check that your policy meets your needs.
Here are the main reasons why claims may be declined:
- Not covered / definition not met
The benefit is not included in the plan and/or the claim does not meet the policy definition for that benefit. For example, a claim is submitted for early-stage cancer, but the plan does not include a cancer benefit, or the policy benefit definition pays only for severe staged cancer.
- Non-disclosure / incorrect information
Important information (e.g. medical history) was not provided or was stated incorrectly when the policy was taken up. For example, diabetes was not declared when the policy was bought. If this was disclosed, we may not have been able to cover you or may have offered you different terms. This can affect your policy, so a later claim may be declined for a related or unrelated condition.
- Exclusion / waiting period / limit applies
An exclusion means the policy does not cover certain conditions, treatments, or hazardous activity e.g. injuries from motor racing are excluded, so a claim for an accident during a race will be declined. A waiting period means your cover starts only after a set time from the policy start/reinstatement date e.g. a benefit has a 90-day waiting period—claims made within the first 90 days will be declined. A limit means there is a maximum payout e.g. if you have fully used your annual limit, any further claim under that benefit may be reduced or declined.
