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Simplifying a Long COVID-19 insurance claim

Long COVID-19 – where patients suffer COVID-19-related symptoms that last at least two months – is a very real health problem for many people. The World Health Organisation defines long COVID-19 as an illness where a patient continues to suffer lingering symptoms of COVID-19 such as fatigue, shortness of breath, cognitive dysfunction “that last for at least two months and cannot be explained by an alternative diagnosis”.

Long COVID-19 is an illness that people can claim from their insurance, depending on their policy. As long COVID-19 has until now not been fully understood, yet were claimed more regularly, financial advisers must know not only on how to process such claims, but also how to guide and assist their clients through this process.

How to streamline the claim process for a client

When a client approaches his/her financial adviser to assist with a claim related to long COVID-19, the client will likely be dealing with emotional and mental stress as they try to juggle their medical treatment with the practical implications on their lifestyle, including work. This is where financial advisers play an invaluable role in offering advice to help facilitate an easier claim process.

• Clarify terms and conditions of cover

Long COVID-19 claims require an incapacity investigation to determine the claimant’s ability to fully perform their occupational duties. Information from the employer, the treating doctor and specialist – such as a physiotherapist – may be required.

The financial adviser must therefore make sure the client understands the terms and conditions of their cover. Certain products – like a critical illness product – have specific claim definitions and claimants may submit claims for conditions that do not meet the defined criteria because it may not yet be at a specified severity level, or the permanence of the condition has not yet been established.

• Be the liaison between the assurer and the specialists

The responsiveness and speed of specialists when it comes to filing reports can have an impact on the claim. Advisers are well placed to find out exactly what the life assurer needs and to communicate this to the doctor and/or specialist.

• Follow up regularly

Advisers should schedule regular follow-ups in their diaries so that they can stay on top of the claim for the client. If there are delays in receiving reports from medical practitioners, make sure that this is communicated to the life assurer promptly.

• Help resolve disputed claims

If the life assurer – for whatever reason – declines a claim, take the time to find out on what grounds it was declined. If the client has cause to appeal the decision, the adviser can help the client submit their appeal to either the life assurer’s Internal Arbitrator or to the Long-Term Insurance Ombudsman, if appropriate.

• Encourage full disclosure

Claimants are sometimes reluctant to reveal certain information as they are worried that it may affect the claim process. Advisers need to reiterate the importance of full transparency. Informed and fair claim decisions are only possible where clear and transparent information is provided. Explain the difference between material and non-material information. Where material information was not disclosed at application stage but becomes evident in the claim’s submission, matters often become complicated. If a claimant provides incomplete information in their claim submission, this can result in the need to request clarity from the claimant or source supplementary information from related third parties such as medical practitioners.

• Dot the i’s and cross the t’s

Claim assessments can be delayed where claim forms are not fully completed or signed. The timeous submission of supporting documents can also cause delays, for example, COVID-19 test results. Where payment is requested into an account that is not the premium paying account, the life assurer will require certain documents as proof of account. If this is not submitted at the time of claim assessment, this could cause claim payment delays.

Other issues that might need to be managed include:

• The claimant reports an inability to work because of a sickness or disability, but the claim submissions lack objective medical evidence to support the claim.
• There may be opposing views on the severity of a condition from different medical practitioners.
• The period claimed for is longer than the typical recovery period for the claimed condition and the extended recovery period cannot be medically substantiated.
• There is a disconnect between the claimant’s understanding of the benefits the policy provides and the policy terms and conditions.

By being aware of all the potential challenges regarding a long COVID-19 claim, financial advisers will not only be able to assist clients appropriately but will also create long-lasting relationships with them.

By Kumeshnie Govender, PPS Group Executive: Life Operations

About PPS

PPS boasts more than 150 000 members who enjoy access to a comprehensive suite of financial and healthcare products that are specifically tailored to meet the needs of graduate professionals.

PPS is the largest South African company of its kind, exclusively for graduate professionals, that still embraces an ethos of mutuality, which means that it exists solely for the benefit of its members. Thus, PPS members with qualifying products from PPS Insurance, PPS Investments, PPS Short-Term Insurance and Profmed share in the profits of PPS Insurance, PPS Investments, PPS Short-Term Insurance and PPS Healthcare Administrators via annual allocations to the unique PPS Profit-Share Account. PPS membership provides access to the following tried, tested and trusted products and services: PPS Life Insurance, PPS Short-Term Insurance, PPS Financial Advisory, PPS Investments and Profmed Medical Scheme. Visit www.pps.co.za for more information. PPS is a Licensed Insurer and Financial Services Provider.