Life and Health Insurance Claims
Life and health claims test document verification, disclosure analysis and the boundary between medical and non-medical (accident) benefits. The amounts are usually fixed by the sum insured or the tariff, so the exam focuses on eligibility and proof.
Life claims
- Insurable interest is tested at inception: the proposer must have a legitimate interest in the life insured.
- Required documents: death certificate, forensic or medical report on cause, beneficiary identification, policy and premium receipts.
- Suicide and certain causes are excluded for a stated initial period; after it, the exclusion lapses unless the wording provides otherwise.
- Non-disclosure or misrepresentation of a material fact at proposal allows the insurer to avoid or reduce, depending on the wording and the statute.
- Accidental-death riders pay only where death results from accident within the stated period, independently of disease.
Health claims
- Check the waiting period, pre-existing-condition exclusion, network provider rules and reasonable-and-customary limits.
- Avoid double recovery where another insurer or social security scheme paid; apply coordination-of-benefits and preserve subrogation against a liable third party.
- Verify medical necessity and that the treatment matches the diagnosis.
Worked example
Death by suicide in year three of a policy with a two-year suicide exclusion. Reasoning: the exclusion period has expired, so the sum insured is payable unless the proposal shows concealment of a relevant psychiatric history; the adjuster requests the medical file before releasing payment.
Traps that cost marks
- Paying an accident benefit for a natural-cause death.
- Ignoring the waiting period for a health claim.
- Missing that a beneficiary nomination was never endorsed.
- Failing to check premium status, which can suspend cover.