Hello friends,

Following on our previous article: Terminal Illness Benefits Part 1 – Summary and Key Points, here are some more key takeaways in part 2.

Introduction: It is the responsibility of the insured, beneficiary or the estate to facilitate and submit the necessary evidence to substantiate the claim or claims, in line with the policy contract requirements. This at times can be tricky and that is why you are going to need the professional help of Repudiated Claims.

Life Cover Benefits:

• Benefit: The specified benefit amount is payable upon the death of the insured while the Life Cover Benefit is active.
• Instant Cash: Some insurers offer a portion of the benefit (up to R50,000) within one working day of a death claim.
• This is available if the insured dies more than two years after the policy start date.
• Payment of this amount doesn’t confirm the validity of the claim. If the claim is denied, this amount must be repaid.

Family Funeral Benefit:

• Benefit: On the death of the insured, their spouse, or child, the specified benefit amount is payable.
• Maximum total claim for simultaneous deaths from the same event is R70,000.
• Benefits cannot be transferred for spouse or child.

Definitions and Benefits:

• Life Insured: R40,000.
• Spouse: R20,000 (coverage ends at age 65).
• Child: R10,000 (coverage for children aged 1 month to 22 years, extendable to 25 if a full-time student or disabled).
• Effect on Life Cover Benefit: Death benefits for spouse or child are additional and do not affect other benefits.
• Payment: Claims are assessed within 48 hours of receiving all documentation, payable to the policy owner or nominated beneficiaries.

Exclusions:

• No payment if the death claim is invalid under Life Cover Benefit.
• No payment for nominated spouse and children during the first 12 months unless death is due to an accident.
• No payment for suicide within two years of policy start or reinstatement.
• Claims must be notified within six months of death.
• Termination of Benefit: The benefit ends upon the insured’s death, term expiry, policy cancellation, or non-payment of premiums (after a 30-day grace period).

Terminal Illness Benefit

Definition:

• If the insured is diagnosed with a terminal illness with less than 12 months to live, the full death benefit can be claimed.
• The policy ceases after this benefit is paid.

Important Considerations:

• Claims are assessed individually, based on merit.
• The process is closed to clients to protect intellectual property and maintain objectivity.
• Claims are based on factual evidence and free from emotional influence.
• Independent operations are crucial, and emotional or personal attacks on the process are avoided.
• The legal team works at no additional cost to the client until the claim is won.
• Approach varies based on the type of claim (e.g., disability, impairment, critical illness).
• Critical illness policies often have waiting periods and specific evidence requirements.
• Multiple claims might be possible under critical illness policies before death, following ASISA (The Association for Savings and Investment South Africa) standards for diseases like heart attack, cancer, stroke, and CABG (Coronary artery bypass graft surgery).

Example: Definition Tiers and Payouts

Definitions cover four tiers: A (most severe) to D (least severe). For “Heart attack” and “Stroke,” insurers can define functional parameters according to their product philosophies.

• The 16 definitions (four diseases, four severities) are standardised, but insurers decide the payout percentage (0-100%) for each severity.
• Insurers can’t pay less for a more severe condition but can pay the same percentage.
• Non-medical conditions can have boosted payouts.


Examples of possible pay-outs could be:


	Insurer 1	Insurer 2	Insurer 3	Insurer 4	Insurer 5
Severity A	100%	100%	100%	100%	100%
Severity B	75%	0%	100%	100%	100%
Severity C	50%	0%	10%	0%	100%
Severity D	25%	0%	10%	0%	100%

It is the responsibility of the insured, beneficiary or the estate to facilitate and submit the necessary evidence to substantiate the claim or claims, in line with the policy contract requirements. This at times can be tricky and that is why you are going to need the professional help of Repudiated Claims.

Contact me at info@repudiatedclaims.co.za or WhatsApp / Call me on 072 240 4354 directly for more information.

Alternative, visit our website at www.repudiatedclaims.co.za for more.

Cheers, Johan