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. WP-KFD-6-02/13