Sharon Williams was hugely thankful for her trauma policy after being diagnosed with cancer. But she hadn’t realised how much haggling would be involved, writes Debra Cleveland.
When business owner Sharon Williams talked insurance with her financial planner, little did she realise she’d be glad of the policy just five months later when she was diagnosed with breast cancer.
Worse, because she was making a claim in the first six months of the policy, she was put through the ringer by the insurance company and initially the claim was questioned.
It was the sheer persistence, she says, of financial planner Gavin Fineff of Sentinel Wealth that got the claim through. This month she will receive about $20,000 from the insurer, on top of another payment she’s already been paid out via an earlier trauma policy taken out by her company, Taurus Marketing, on her behalf.
But it’s a stark reminder that even with the right policy and the correct claim procedure, things can go wrong. Fineff says the trouble started because Williams’ diagnosis occurred within six months of her policy being set up.
“It was a massive trigger for the insurance company,” he explains. “It opened up a whole new world of investigation to see if it was a pre-existing condition. It was painful [for Sharon] but I knew our position from the start. I knew Sharon’s situation and the strength of her claim.”
A key sticking point was that Williams had disclosed that her doctor had told her that after reaching a certain age she was eligible for free mammograms. She had not done so, she says, as she had no symptoms.
The insurer was extremely sceptical of this, as she had not followed her doctor’s recommendation. But Fineff argued it had been a recommendation rather than a directive. To back this up, he had to access the doctor’s clinical notes, confirm the doctor’s position on the recommendation, chase BreastScreen NSW to confirm no mammograms were done and therefore nothing had shown up to prove any pre-existing condition.
OPPORTUNITIES NOT TO PAY OUT
“The point is they’ve got such a strict claims process that if the claim application or supporting information is different from that, it’s an opportunity not to pay,” Fineff says.
Williams was diagnosed with early breast cancer in October 2014 and had two lumpectomies. “When I was diagnosed I happened to be catching up with Gavin for our six-monthly meeting and told him about it,” she says. “He rang me a few weeks later and said I was in a position to make a claim.
“I hate filling in forms so he filled them all out and I signed them. He kept pursuing it – he was like a dog with a bone.”
When the first policy was paid out, “I couldn’t speak for days; I was in complete shock”. The payout helped cover not only the medical procedures costs, but also a range of alternative treatments, supplements and dietary changes as well as payments to staff, who covered her for absences during her treatment.
“The kindness of Gavin looking after me and the fact that I was going to get covered lessened some of the pain and the heartache.”
Had Williams’ condition worsened to the extent of having to have a mastectomy, Fineff says, both policies would have paid out 100 per cent – $100,000 on the personal policy and $200,000 on the company policy. As it was, both policies paid out 20 per cent.
ASK THE RIGHT QUESTIONS
Financial planner Anne Graham, managing director of McPhail Financial Planning, says following through insurance claims can be laborious and time-consuming – and at times heartbreaking.
“The most difficult was a terminal illness claim for a woman in her early 30s. The difficulty was that the policies were owned by super funds so there were two levels of bureaucracy to deal with,” Graham says.
The first was meeting the medical requirements of the insurance policy: “It was mainly getting the paperwork together and having specialists sign off.”
The second was meeting the eligibility requirements of the funds to pay the benefits. “There were three to five different super funds involved and some were very easy to deal with and one in particular was extremely difficult,” Graham says. “So [difficult] in fact that the client passed away before the terminal illness benefit was paid and we had to start the process again because it was then a death benefit.”
Advisers can be more successful with the claims process, Graham says, because they have relationships with insurers and understand how the process works and the definitions of the policies.
“They know the right questions to ask and who to speak to in terms of cutting through call centres and the like,” she explains. “When a client is dealing directly with an insurer at claim time, they are usually stressed due to the health and financial issues and they aren’t familiar with the process.”
Graham confirms Fineff’s stance that it’s the adviser’s job to deal with the claim so the client can concentrate on getting better.
Williams says she is doubly appreciative of Fineff’s efforts given there were no commissions involved.