Definitions of Terminal Illness Benefit

Example 1:

• If the insured is diagnosed with a terminal illness expected to result in death within 12 months, the policyholder can claim the full death benefit.
• The policy will terminate once the claim is paid.
• Claims cannot be made in the last 24 months of coverage if the policy is not lifelong.

Example 2:

• The insured can claim the full death benefit if diagnosed with a terminal illness expected to result in death within 12 months, as per the insurer’s Chief Medical Officer.
• The policy and all its benefits end upon payment of the terminal illness benefit.
• Applies to both “Stand Alone” and “Accelerated” benefits.

Important Notes on Claims Process:

• Each claim is assessed on its merits based on factual evidence, not emotions.
• The process is confidential to protect intellectual property and avoid emotional involvement.
• Decisions are based on rules, case law, and precedent but each case is unique.
• The approach varies based on claim type, and multiple claims may be involved.
• Terminal illness claims should be handled with caution, ensuring other claims are finalised first.

Types of Claims and Considerations:

1. Terminal Illness and Death Claims:

• Prioritise completing all other claims before filing for terminal illness or death benefits.

2. Disability and Impairment Claims:

• Often require a waiting period (3-6 months).
• Payouts are usually based on a percentage and must be confirmed by a specialist.

3. Critical Illness Policies:

• Cover many conditions and require proper evidence.
• Usually have a survival period (30-90 days).
• Multiple conditions can be claimed before death if policies are reinstated.

Most critical Illness policy covers re-instate again after 30 days.

Depending on the type of claim or the percentage % that was paid.

You can easily have X 4 different types of claims, as shown under the SCIDEP definitions.

Repudiated Claims can professionally assist you with this, before you proceed with the Terminal Illness claim.

ASISA SCIDEP Definitions:

• Standards for critical illness claims focus on four core diseases: heart attack, cancer, stroke, and coronary artery bypass graft (CABG).
• Definitions have four severity tiers (A-D), with varying payout percentages at the insurer’s discretion.
• Insurers cannot pay less for more severe conditions but can equalise payouts across severities.

	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%

Claims Process:

• The insured, beneficiary, or estate must provide evidence to support claims according to policy requirements.
• Professional assistance by RC may be beneficial to navigate this complex landscape.

Claims Declined During the Last Three Years 

Table Interpretation and Simplified Layout:

Year	Number of claims declined	Common reasons for decline
2021	150	Inadequate evidence, late submission
2022	170	Failure to meet survival period, incomplete documents
2023	200	Not meeting policy terms, incorrect filing procedures

This table illustrates the number of claims declined over the past three years, highlighting common reasons for rejections such as inadequate evidence, not meeting survival periods, and failure to adhere to policy terms.

Summary:

Terminal illness benefits allow the insured to claim the full death benefit if diagnosed with a terminal illness expected to result in death within 12 months. However, it is crucial to carefully manage and prioritise all other potential claims and understand the specific requirements and processes to avoid claim rejections. Professional assistance may be beneficial to navigate this complex landscape.