Life and disability claims

Objective
To develop in the candidate: • a knowledge and appreciation of the claim considerations for life and disability and critical illness insurance; • a knowledge of the legal, medical and financial factors; • the ability to apply knowledge and skills to practical situations; • the ability to synthesise different aspects of the syllabus and apply them to given scenarios.

Summary of learning outcomes
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Introductiontoclaimsmanagement Initialclaimconsiderations Claimsassessmenttools–whatisavailableandwhentousethem Financialassessment Determiningvalidityoftheclaim Legalandregulatoryissuesatclaimstage Actuarialconsiderationsandreassurance Disabilitytermsandconcepts Disabilityassessment Medicalaspectsofclaimsassessment Rehabilitation

Important notes
• ThesyllabusisexaminedonEnglishlawandpracticeunlessotherwisestated. • TheAprilsessionwilltestthelegalpositionasof31stAugustoftheprecedingyear. • TheOctobersessionwilltestthelegalpositionasof28thFebruaryofthesameyear.

2012

© The Chartered Insurance Institute 2011

556

• explain the use and purpose of financial questionnaires and other financial evidence.5 Groupandindividualbusiness Candidates should be able to: • explain the differences of approach between group and individual claims. – hospital cash.1. • discuss the procedure and explain the implications in respect of a lost policy. 2012 © The Chartered Insurance Institute 2011 2of6 . – accident. – claimant expectation. 3. • explain the legal and industry guidelines for the use of private investigators.7 3. including the approach to: – customer service. 1.2 Claimsphilosophy Candidates should be able to: • explain the claims philosophy of a life office. • describe the procedure in respect of proof of age. 3. including: – income protection/mortgage protection and waiver of premium. 1. – vocational assessments.3 Claimsforms.1 Initialclaimconsiderations Policyinforce Candidates should be able to: • determine whether a policy is in force. including: – long-term care. • discuss the procedure in respect of a lapsed/paid up policy.notesandexaminations Candidates should be able to: • describe the use and purpose of – GP reports and notes.6 Filemanagement Candidates should be able to: • explain the importance of file management and the implications of poor file management. • explain the role and procedures of the coroner.5 Homeandemployervisits Candidates should be able to: • explain the use and purpose of home and/ or employer visits in the handling of life and disability claims. 3. – terminal illness and permanent total disability. 1. • discuss the principles of underwriting.4 Privateinvestigators Candidates should be able to: • explain the use and purpose of private investigators.questionnairesandother evidence Candidates should be able to: • explain the use and purpose of occupational questionnaires and job descriptions.2 Medicalreports.2 Underwriting Candidates should be able to: • discuss the importance of reviewing the proposal form and underwriting papers.1 Introductiontoclaims management Roleoftheclaimsdepartment Candidates should be able to: • describe the role of the claims department.4 Majorbenefittypes Candidates should be able to: • discuss the major benefit types. – consultant reports. • discuss the principles of risk management.3 Productcontrolcycleandriskmanagement Candidates should be able to: • discuss the product control cycle. 3. 1. – functional assessments. – early intervention. 1. 3. 2. – independent medical examinations. Proofofdeath Candidates should be able to: • explain the procedures and documentation required for death claims.1 Claimsassessmenttools–whatis availableandwhentousethem Communication Candidates should be able to: • explain the importance of effective briefing and questioning communication used in the claims handling process. • describe the other benefit types. 2. 3. 3. – critical illness. 2. • explain the importance and use of claim forms. 1.6 Occupationaltherapists Candidates should be able to: • explain the role of occupational therapists in life and disability claims assessment. – death.

– dividends. including: – benefits in kind.6 Proportionateandrehabilitationbenefits Candidates should be able to: • discuss the purpose. 5. Companies House and the ABI register are used to assist with life and disability claims processing. – eligibility. 4.2 Limitationofbenefit Candidates should be able to: • assess the application and implications of limitation of benefit. 4. – switched schemes. nature and effect of other financial considerations. particularly in relation to: – income/mortgage protection. – critical illness. – accountants. – death in service.3 Proceduresforincomeprotectionclaimsand waiverofpremium Candidates should be able to: • discuss the procedures for regular payment claims and waiver of premium. – drawings. – policyholder/spouse who run their own business. 4. – scheme salary. 4. 4. 5. – pre-existing conditions. – employed directors. including: – chief medical officers. 2012 © The Chartered Insurance Institute 2011 3of6 .4 Otherfinancialconsiderations Candidates should be able to: • discuss the purpose. – solicitors.1 Financialassessment Financialunderwriting Candidates should be able to: • describe the financial underwriting considerations applicable to the following types of claim: – income protection.terminalillnessandtotal permanentdisablement Candidates should be able to: • assess the issues in relation to the interpretation of definitions for critical illness.5 Criticalillness. – termination of employment. – personal service providers. – combined business structures.2 Theroleofexperts Candidates should be able to: • describe the role and use of experts in life and disability claim handling. including exclusions. – rights of third parties.1 Determiningvalidityoftheclaim Claimpolicyconditions Candidates should be able to: • assess the nature and application of standard claim policy conditions for each benefit type.3.3 Employmenttypes Candidates should be able to: • evaluate the importance of the following forms of employment and the evidence required for claims assessment: – employed. – group income protection benefits. – assessment and entitlement to those Benefits. terminal illness and permanent total disablement claims. 5. – death. – commission.5 StateBenefitsystem Candidates should be able to: • describe the State Benefit system and in particular: – available Benefits. – depreciation. – key person/locum cover.4 5. 5. – self employed. – total permanent disability. 4. – free cover. – partnerships. 5. Groupclaims Candidates should be able to: • discuss the issues posed by the following for group claims: – actively at work.8 Sourcesofinformation Candidates should be able to: • explain how other sources of information such as the internet. – pension. 4. nature and application of proportionate and rehabilitation benefits.

6. – provisional/on account. • explain the role and procedures of the Financial Ombudsman Service.2 Determiningandrespondingtofraud Candidates should be able to: • discuss the methods for determining and responding to fraud. including the FSA complaint handling rules. – Protection from Harassment Act 1997.6 Determiningtitle Candidates should be able to: • assess the issues affecting the determination of title. – assignment. including: – death. – power of attorney. 6.6 5. – Life Assurance Act 1774. and discuss how strict law is modified. – Unfair Contract Terms Act 1977.7 Agency Candidates should be able to: • describe the implications of use of agency and the role of the agents in life and disability claims. Confidentialityandthehandlingofpersonal andsensitiveinformation ABICodesofPracticeandtheFSAICOB Rules Candidates should be able to: • evaluate the role and impact of the ABI Codes of Practice and the FSA Insurance Conduct of Business Rules on life and disability claims. – Disability Discrimination Act 1995/ Equality Act 2010.3 Utmostgoodfaith Candidates should be able to: • discuss the application of utmost good faith to life and disability claims. – Proceeds of Crime Act 2002.5. – duty at claim stage. 2012 © The Chartered Insurance Institute 2011 4of6 . – Unfair Terms in Consumer Contract Regulations 1994. 6. 6. including: – duty at proposal.1 Legalandregulatoryissuesat claimstage Non-disclosureandmisrepresentation Candidates should be able to: • explain the classifications of nondisclosure and misrepresentation.8 Disputeresolution Candidates should be able to: • describe the appeals process in relation to a claim.8 Non-contractualprovisions Candidates should be able to: • discuss the operation and implications of the non-contractual provisions.10 Decliningclaims Candidates should be able to: • discuss the recommended procedures for declining claims and the implications thereof. – Current money laundering regulations. – Human Rights Act 1998.7 Overseasclaims Candidates should be able to: • discuss the issues applicable to overseas claims.5 6. – The Access to Health Records Act 1990. 6. • assess the remedies for each. – ex-gratia payments. 6. – Court of Protection orders. including: – commuted values.4 Legislation Candidates should be able to: • outline the main provisions of the following pieces of legislation and their application to life and disability claims: – Financial Services and Markets Act 2000. – bankruptcy. 5. 5. 5. – Access to Medical Reports Act 1988. – Contract Rights of Third Parties Act 1999. – duty at commencement/reinstatement. 6.9 Non-disclosure Candidates should be able to: • discuss the identification of non-disclosure in relation to a claim. • describe the current legal environment that applies to declining claims • discuss the use of contractual and other types of arbitration. including fraud conditions. • discuss the evidence required to investigate suspected non-disclosure. 6. – Data Protection Act 1998. – trusts.

11.1 Assessmentofskills Candidates should be able to: • describe the assessment of social and communication skills.1 Generalconsiderationsandproductspecific details Candidates should be able to: • discuss general medical considerations in respect of claims assessment. • explain how the outcomes of rehabilitation are evaluated. – neurological disease and injuries.2 Reassurerandreassurance Candidates should be able to: • describe the role of the reassurer and the types of reassurance available. – renal problems. • discuss the process of rehabilitation including early intervention. – handicap. – impairment. for both disability and tpd.1 Actuarialconsiderationsand reassurance Actuarialaspects Candidates should be able to: • outline the actuarial aspects of life and disability claims. – commuted values.1 Disabilitytermsandconcepts Definitionofterms Candidates should be able to: • describe the differences between the following terms: – disability. – functional capacity. 2012 © The Chartered Insurance Institute 2011 5of6 . 9.2 Modelsofdisability Candidates should be able to: • describe the definition of different models of disability specifically own occupation suited any activities of daily living and work. – occupation. 10.7. – incapacity. 9. 10 Medicalaspectsofclaims assessment 10. – respiratory diseases. 8. 7. 10. – financial considerations.4 Theroleofthegeneralpractitionerin certifyingfitnessandunfitnessforwork 7. 8.1 Disabilityassessment Factorstoconsider Candidates should be able to: • evaluate the impact of the following factors in relation to disability claims assessment. – medical conditions.2 Subjectiveandvariableconditions Candidates should be able to: • discuss the assessment of subjective and variable conditions.2 Rehabilitation Candidates should be able to: • discuss the principles of rehabilitation and their relevance to claims assessment. – cardiovascular diseases. mental and physical. medical specialists and the Department for Work and Pensions. Rehabilitation 11. 11. 11. including: – musculo-skeletal problems. – experience analysis. – sensory disabilities – vision and hearing. – functional limitations. • describe the possible outcomes and alternatives to previous employment.3 Multipleimpairments Candidates should be able to: • discuss the implications of multiple impairments. • describe the personal and social aspects of rehabilitation. including: – inception and termination rates. • describe the assessment and guidance for non-work activities. – social factors. • discuss the assessment for return to work. – claims reserves. – cancer. – actuarial control cycle. – motivation. – mental health problems. 8.3 Rehabilitationagenciesandspecialists Candidates should be able to: • explain the role of other agencies. 10.

London: Palgrave Macmillan. Available online at www. • Houseman’s Law of life assurance. 11th ed. London: Incisive Financial Publishing. Periodicals and publications listed will be of value in ensuring candidates keep up to date with developments and in providing a wider coverage of syllabus topics.knowledge.co. • Life and disability claims. Periodicals • Cover. Available online at www.cii. Updated as necessary. • Post Magazine.co. detailed works which should be used selectively as and when required. 2004.co. 2006.cii. Ross Mackenzie. Brian Murphy.uk to buy online or contact CII Customer Service for further information on 020 8989 8464.knowledge.co. You will also find advice at www. • The Journal. Haywards Heath.uk/career-support (CII/Personal Finance Society members only). 2nd ed.uk/category/resource-type/ exam-guides. Also available online (CII/Personal Finance Society members only) at www. CII/Personal Finance Society members can borrow some of the additional study materials below from Knowledge Services.knowledge. C Bennett. 1991. 2006.uk/ category/resource-type/fact-files (CII/Personal Finance Society members only). Older examination guides are available (for members only) at www. Robert Surridge. Also available online at www.uk/ category/resource-type/fact-files (CII/Personal Finance Society members only).uk. London: CII Knowledge Services.co. 3rd ed. Updated as necessary.co. Monthly. Reference materials • Brackenridge’s Medical selection of life risks. You are strongly advised to study guides for the last two sittings. 2007. • Further articles and technical bulletins are available via www. London: Pearson Education. Any reference materials cited are authoritative. London: CII Knowledge Services.cii. Weekly. Editors.knowledge.co. 2012 © The Chartered Insurance Institute 2011 6of6 . For further information on the lending service. • Recent developments in life assurance law. 2008.knowledge. Robert Surridge.cii. West Sussex: Tottel. Six issues a year.uk Examination guides Guides are produced for each sitting of written answer examinations. Richard S Croxson. You should choose one which suits your requirements.knowledge. Tony Wiltshire. The reading list is provided for guidance only and is not in itself the subject of the examination.cii. London: CII.knowledge. London: Buckley Press.cii. London: Informa. Exam technique/study skills There are many modestly priced guides available in bookshops.co. London: Sweet & Maxwell. Monthly. • MacGillivray on insurance law: relating to all risks other than marine.Reading list The following list provides details of various publications which may assist with your studies. Abingdon (Oxfordshire): Routledge-Cavendish.cii. • Dictionary of insurance.uk/category/resource-type/journal.knowledge. London: CII.cii.uk/resource/dictionary-insurance (CII/Personal Finance Society members only). • Life assurance contracts. • The regulation of retail investment business. R D C Brackenridge. These include the exam questions. Note:Theexaminationwilltestthesyllabusalone. Noleen John. 13th ed.co.cii.cii. Coursebook 556. • Health Insurance & Protection. examiners’ comments on candidates’ performance and key points for inclusion in answers. London: Incisive Financial Publishing. Andrew McGee.co. Distributed by Incisive Financial Media. Websites • CII Knowledge Services – www.uk (CII and Personal Finance Society members only). CII study texts can be consulted from within the library. please go to www. • Guide to life assurance underwriting. 5th ed.knowledge. Keith Sankey. Please visit www.

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master Your Semester with a Special Offer from Scribd & The New York Times

Cancel anytime.