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COBS 17.1 Providing information to claimants and dealing with claims

COBS 17.1.1 R

1When an insurer or managing agent receives a claim under a long-term care insurance contract, it must respond promptly by providing the policyholder, or the person acting on the policyholder's behalf, with:

  1. (1)

    a claim form (if it requires one to be completed);

  2. (2)

    a summary of its claims handling procedure; and

  3. (3)

    appropriate information about the medical criteria that must be met, and any waiting periods that apply, under the terms of the policy.

Responding to a claim

COBS 17.1.2 R

As soon as reasonably practicable after receipt of a claim, the insurer or managing agent must tell the policyholder, or the person acting on the policyholder's behalf:

  1. (1)

    (for each part of the claim it accepts), whether the claim will be settled by paying the policyholder, providing goods or services to the policyholder or paying another person to provide those goods or services; and

  2. (2)

    (for each part of the claim it rejects), why the claim has been rejected and whether any future rights to claim exist.

Rejecting a claim

COBS 17.1.3 R

An insurer and a managing agent must not:

  1. (1)

    unreasonably reject a claim; or

  2. (2)

    except where there is evidence of fraud, reject a claim for:

    1. (a)

      non-disclosure of a fact material to the risk which the policyholder could not reasonably have been expected to disclose; or

    2. (b)

      misrepresentation of a fact material to the risk, unless the misrepresentation is negligent; or

    3. (c)

      breach of warranty, unless the circumstances of the claim are connected to the breach, the warranty is material to the risk and was drawn to the policyholder's attention before the conclusion of the contract.