Group Income Protection Claims philosophy
What
An integral part of the claims process for group income protection schemes is the ability of our claims management team to be able to investigate and understand the events giving rise to a claim and provide important support to you and your employee until such time as they are able to return to work.
When
- You should notify us when an employee has been continuously absent from work for one month (or has worked on a reduced basis for a period greater than one month) due to injury or illness by completing and submitting a notice of absence form.
- A formal claim for benefit should be made by you as soon as reasonably practicable but in any event no later than 6 weeks before the end of the deferred period.
Who
Once we receive the completed claim forms we will confirm your main claims handler, together with their contact details, so that you can get in touch with us quickly and easily if you have any questions or queries.
How
- Initially a notice of absence form;
- Claim forms are then completed by both you and the employee, including details such as the full duties of their occupation, what is preventing them from working, their salary, etc; and
- A signed and dated claim consent form which allows us to process sensitive personal data and obtain medical reports and information.
- This process varies depending on the circumstances of each specific claim, but could involve any of the following:
- A report from the employee’s GP, together with any relevant hospital notes and reports. This should provide us with full details of the medical history and current condition;
- A report from any treating Consultant or Specialist, if appropriate; and/or
- A home and/or workplace visit, usually by an Occupational Therapist. The visitor will meet with the employee and/or yourselves in order to gather information to aid our assessment of the claim and to help the employee recover as fully as possible and deal with the implications of long term incapacity. To do this they will consider the employee’s functional capacity, identify the barriers preventing a return to work, advise on graded rehabilitation programmes and offer advice on what individuals can do to help themselves.
We always reserve the right to obtain further independent medical evidence, investigations or examinations if required.
Once in receipt of all of the required evidence, we will advise you whether the claim has been accepted and confirm the amount of benefit payable. Benefit is payable monthly in arrears, from the end of the deferred period as specified in your policy schedule. Benefit will continue, subject to regular medical reviews, until one of the following occurs:
- The employee returns to work;
- The employee reaches termination age;
- The employee dies;
- The employee’s membership of the scheme or employment is terminated;
- The employee recovers and no longer satisfies the definition of incapacity;
- There is a breach of the employer or employee’s obligations under the policy.
Frequently Asked Questions
Where can we get claim forms?
All claim forms are available from the claims section of the EB documents library
Does the employee always have to attend a medical examination?
It depends on the individual circumstances of the case. Often the information provided by the employee’s own doctors will be sufficient but we reserve the right to request further information if we feel it is required to fairly assess the claim.
Who pays for the medical evidence?
When we ask for medical evidence we will pay for it. If the employee is located outside of the UK, we will cover the cost up to the equivalent of the UK cost. Any excess will be your responsibility.
How much benefit will the employee receive?
This varies depending on what level of cover was requested when the scheme was set up. Typically a claim would be 75% of the employee’s gross pre-incapacity salary less state incapacity benefits.
Do you make payments directly to the employee?
Benefit is always paid to you as the employer and you should pass it on to the employee through your normal PAYE procedures.
What happens if an employee receiving benefit leaves our employment?
Payments will cease upon the employee leaving service.
Can a lump sum payment be made?
The policy is designed to pay a monthly benefit however, in certain circumstances, a lump sum settlement may be the most appropriate solution for all parties. This falls outside of the standard terms of the policy and should be discussed and negotiated with your claims handler on a case by case basis.
How often are claims reviewed?
The frequency of review is geared to the individual circumstances of the case and you will be advised when the next review will take place.
What happens if an employee is not fully recovered but returns to work in a reduced capacity?
A partial benefit may be paid at our discretion to support employees in this situation. The level of benefit paid will be such that it is financially advantageous to the employee to return in a reduced capacity whilst maintaining an incentive to return to full-time work.
What happens if an employee becomes incapacitated again shortly after returning to work?
Provided the new period of absence is within 6 months of the return to work and for the same medical cause as the previous claim, we can waive the requirement for a deferred period to be served and recommence benefit payments immediately (subject to supporting medical evidence).
Can we appeal if a claim is unsuccessful or we are unhappy with the outcome of a review?
If you are unhappy with the handling of a claim, including any decision in respect of a claim, or if your employee has expressed dissatisfaction, you should direct your complaint in the first instance to our Customer Relations Officer at: Assicurazioni Generali S.p.A, 100 Leman Street, London, E1 8AJ.
If you remain dissatisfied with the outcome of our investigation, then you may be able to refer this matter to the Financial Ombudsman Service, subject to the jurisdiction of the Financial Ombudsman Service:
Financial Ombudsman Service,
South Quay Plaza,
183 Marsh Wall,
London, E14 9SR
Telephone: 0845 080 1800
Email: enquiries@financial-ombudsman.org.uk
Website: www.financial-ombudsman.org.uk
Making a complaint will not prejudice your right to take legal proceedings.