A Guide to making a Claim
Here we explain our claims process, what we might ask you in relation to your claim and, most importantly, what you can expect from us.
Initial Claim Documentation
Along with this brochure, you should also have received your claim form which includes the medical certificate and a occupational questionnaire.
The purpose of these documents is to help us gather as much information as possible about your sickness/injury so we can efficiently assess your benefit requirements.
Medical Certificate - This needs to be completed in full by the medical professional treating you and sent to us with your claim form.
Occupational Questionnaire - You must complete this and return it to us with your claim form and medical certificate. The information in this document helps us to understand your pre-disability capacity.
Further Medical Evidence
After we receive your claim forms and medical certificate from your treating doctor, we may require further medical evidence. If this is the case, we will use the authority given by you to obtain up-to-date and more detailed information from your past and present medical providers.
Independent Medical Examination
As part of our claim assessment, we may request that you undergo an examination by an independent medical specialist.
Examinations are arranged for a number of reasons, including:
- Review and confirmation of your level of disability.
- Review of your treatment and management plan.
- Independent confirmation of your diagnosis.
Any suggestions the specialists make will be forwarded to your treating medical providers, as they (and you) are responsible for your ongoing treatment.
You may be asked to provide proof of your income for a period prior to becoming disabled. You will always be asked to provide details of income you continue to earn during any claimable period.
If we have requested that you provide us with financial accounts, this is required under the contract to establish entitlement or we anticipate these are likely to be required for a partial disablement claim.
Assessing Your Claim
As soon as we receive your completed claim form and supporting documentation, we can begin to assess your claim. We are not able to establish your full entitlement to a claim while any of this information is outstanding.
Return to Work and Rehabilitation
Our primary aim in managing your claim is to ensure that you are able to commence a safe return to work as soon as possible.
Many MAS policies provide a rehabilitation benefit. This allows us to assist you in meeting the costs of formal rehabilitation programmes and assistive devices that you may need to return to work. These costs are met in addition to your weekly benefits.
What We Require From You
Your Personal Details
We may need to write or speak to you about your claim and/or policy. Please keep us updated as to any changes to your address or contact details (including email address).
Change in Circumstances
During your claim you must immediately advise us of any change in your circumstances. This will include changes in your medical condition or ability to work.
Access to Personal Medical Records
Like any prudent insurer, MAS strives to ensure that premiums are kept as low as possible. One way we achieve this is by ensuring that only legitimate claims are paid. Unfortunately in a small number of cases, policies are taken out where a complete medical picture has not been disclosed.
To ensure that this is minimised, your claims adviser will review your medical history when you make a claim. This may be as simple as comparing the information disclosed when you applied for the policy with the information provided in your claim. In the majority of cases there is no need for further action.
In some circumstances we need a more detailed picture of your medical history. This may involve assessing your medical records from your current and past treating healthcare providers.
When you complete your claim form you are asked to sign a consent which will allow us to obtain details of your past medical history. All members are requested to sign these authorities when a claim is first made. However we only seek access to your records if we believe there is a need to do so or our claims handling guidelines require it.
Your First Payment
Payments are usually made four weekly in arrears and the first payment will be made four weeks after your waiting period has expired.
All payments are made to the policy owner, or as directed by the policy owner.
We appreciate that you have purchased this policy to provide financial assistance in the event that you are unable to work due to sickness or injury and that your financial commitments will continue while we assess your claim. If there is an unreasonable delay in us being able to formally accept your claim, such as a need to obtain medical records, we may decide to make provisional payments to the policy owner.
Such payments will be made without acceptance of liability by MAS and on the basis that the policy owner agrees to repay the benefits if we are unable to accept your claim.
Provisional payments will not be available where we consider it unlikely we will be able to accept your claim, or where you cause us a delay in receiving information that we need to asses your claim.
Ongoing Claim Documentation
Your policy definition will likely have two medical aspects:
- You suffer from a sickness or injury.
- You are under the care of a medical practitioner.
In order to be entitled to benefits, you must continue to satisfy these requirements and must provide us with satisfactory evidence of this.
This evidence is predominantly taken from ongoing claim forms called progress reports. We usually require progress reports to be completed monthly throughout the duration of your claim.
We encourage you to ring your MAS claims adviser and keep them advised of your progress or any change in your condition, where possible. Your MAS claims adviser is able to answer any questions you may have about your claim and your entitlements under your policy, and will be only too pleased to help.
From time to time your MAS claims adviser may contact you about your claim and your medical condition.
Please note that we may record and store telephone calls to and from our Member Support Services. We do this to have a record of the information we receive and give over the telephone. This also helps us with quality assurance, continuous improvement and adviser training.
Your call will be handled in complete confidence, except to the extent that we are authorised to discuss any aspects of or other information relating to your claim with other persons, subject to the Privacy Act 1993 and Health Information Privacy Code 1994.