Group Life Assurance Claim & Medical Records Request

AP3

Hi All,

I suppose I'm asking this out of curiosity.

My wife sadly passed away in February, from cancer that was initially diagnosed in 2019.

A claim has been made via her employer on their Group Life Assurance (death benefits). It was approved by the trustees in March, then sent to the insurer for payment.

Apparently there is a ping-pong match of questions and answers going on between the employer and the insurer.

For some reason, the insurer won't talk to me directly, and just refer me back to the employer if I try to find out what is causing the delay. The employer just says that the claim is being reviewed.

I've now been asked to, and have, given the insurer permission to access my late wife's medical records. But I'm at a loss to understand why they would need access to these?

My wife first started working for this employer in 2006, and was perfectly healthy at the time.

Any clues as to what on earth they might be looking for?

TIA

DullGreyGuy

AP3 said:

I suppose I'm asking this out of curiosity.

My wife sadly passed away in February, from cancer that was initially diagnosed in 2019.

A claim has been made via her employer on their Group Life Assurance (death benefits). It was approved by the trustees in March, then sent to the insurer for payment.

Apparently there is a ping-pong match of questions and answers going on between the employer and the insurer.

For some reason, the insurer won't talk to me directly, and just refer me back to the employer if I try to find out what is causing the delay. The employer just says that the claim is being reviewed.

I've now been asked to, and have, given the insurer permission to access my late wife's medical records. But I'm at a loss to understand why they would need access to these?

My wife first started working for this employer in 2006, and was perfectly healthy at the time.

Any clues as to what on earth they might be looking for?

Sorry for your loss

In an employers policy the company is the policyholder, the employees are the insured lives and you are a beneficiary. Often there is a Master Trust which will have trustees.  Insurers typically will only speak to their policyholders or trustees hence them directing you through them.

I've never dealt with Group Life so can't suggest what they are looking for in the medical records, it's a very different product to personal life insurance. Was she working for a very small employer? Did she have a particularly large benefit? 

dunstonh

I've now been asked to, and have, given the insurer permission to access my late wife's medical records. But I'm at a loss to understand why they would need access to these?

Nobody here will be able to answer it specifically but it could be a rang of issues.

Usually, with group schemes, the employees are not medically underwritten individually up to a certain amount.   However, the employee may request further cover beyond the default, and that may require underwriting at the point of application (of the increase).  That is often a simplified range of questions that the employee answers at point of application that depending on the answers, may require an underwriting referral before being accepted.  

So, using an example, you say your wife was diagnosed in 2019 (although it's the symptoms that decide the date, not the diagnosis - so it could be 2018).  If she had the default life cover then she should be fine in that respect.    However, if she applied for an increase above the default after the symptoms were occuring and didn't declare the medical issues, then the insurer may reject the increased amount.

That is just one example.  There may be others.

TELLIT01

Purely guessing at the reason, but it could potentially be a large payout and the insurer wants to ensure that any known medical history was declared at the time the policy was taken out. 

DullGreyGuy

TELLIT01 said:

Purely guessing at the reason, but it could potentially be a large payout and the insurer wants to ensure that any known medical history was declared at the time the policy was taken out. 

With Group Life you dont typically declare anything for those with a future payout under a certain amount, with Aviva it used to be £2m. If you do have someone with a benefit over the threshold it's normally a one and done so even if their benefit changes in the future it doesnt need to be repeated. 

The little bit I have done in this space the rules are slightly different with very small firms, in Aviva's case it was companies with less than 20 members in the policy but it still had a underwriting free amount, just lower than the £2m 

Weighty1

DullGreyGuy said:

TELLIT01 said:

Purely guessing at the reason, but it could potentially be a large payout and the insurer wants to ensure that any known medical history was declared at the time the policy was taken out. 

With Group Life you dont typically declare anything for those with a future payout under a certain amount, with Aviva it used to be £2m. If you do have someone with a benefit over the threshold it's normally a one and done so even if their benefit changes in the future it doesnt need to be repeated. 

The little bit I have done in this space the rules are slightly different with very small firms, in Aviva's case it was companies with less than 20 members in the policy but it still had a underwriting free amount, just lower than the £2m 

With many insurers it's normally close to around the £600,000 mark, certainly on schemes with less than 50 employees, although some (I think Aviva used to historically do this, but no longer) offer an increasing level of free cover with each employee.

There are some eligibility questions that are normally asked, such as whether there's been any employees absent from work for more than 3-months on the inception date of the plan OR how many employees have suffered a 'serious' illness in the 12-months prior to the plan being placed into effect.  Serious being defined as heart attack, cancer, stroke or a terminal illness.  I'm guessing that maybe the insurer are just trying to determine that the OP's wife had not had any of these conditions prior to being insured on the plan (not that this would be a non-disclosure issue on her part, more that of her employers) and that she'd not been absent for >3-months at the time when she first became insured.

Who knows *shrug* but the chances are, as you'll be aware, it's probably just all part of the claims process.

AP3

Thank you to everyone for replying.

Her employer was fully in the loop regarding her diagnosis and treatment, so I can't imagine that they haven't been able to give the insurer (L&G) all the relevant information.

It is a very large international company (market cap. >$330bn) with 50k+ employees worldwide.

The figure in question is very large (close to 7 figures), and she did pay a monthly sum to increase it from the default 3x salary offered by the employer, to 8x salary.

I don't recall when she did this exactly, but this might explain it, however the date she increased it, and her diagnosis date (within a week of noticing symptoms), should be readily available from the employer, hence my wondering what medical records would be needed for.

I guess I'll find out in the fullness of time, hence asking out of curiosity.