When investigating and assessing an injury or illness insurance claim, an insurer is entitled to make reasonable enquiries which are necessary for it to make a decision on the claim. So, if you’ve made a claim for TPD, income protection, trauma insurance or life insurance, what would be considered “reasonable enquiries” being made by the insurer and do you have to answer all their questions?
What information does the insurer often request?
As a matter of course, as part of an insurance claim, an insurer will make a number of requests for information. These requests may include:
- That you complete a claim form;
- That you have your doctor complete a claim form (often called a Medical Attendant’s Statement or Attending Doctor’s Report);
- That your former or current employer complete a claim form (often called an Employer’s Statement);
- That you provide further medical records or a further medical report from your treating doctors;
- That you provide (or authorise the insurer to request) copies of your Income Tax Returns or Notices of Assessment, Pharmaceutical Benefits Scheme or Medicare claims history or Centrelink file;
- That you attend a medicolegal appointment with a doctor of their choice.
The above is not an exhaustive list and the way that the claim is assessed differs from claim to claim, depending on the policy details and the facts and circumstances relevant to the claim.
Interview requests from insurers
One thing that insurers sometimes do, is request that you attend an interview with an investigator. They often call these interviews “factual interviews” and they are sometimes conducted by external companies engaged by the insurer or they are completed by in-house staff. Sometimes these investigations are completed by former police officers specially trained to do this work.
Prior to going to any factual interview, you should demand a detailed list of the questions which are going to be asked.
Because these interviews are often scheduled without you realising the facts and matters which the insurer is seeking to investigate (or even that you are being investigated), we recommend that prior to going to any factual interview, you demand a detailed list of the questions which are going to be asked.
An insurer may deny this request and instead give you a broad-strokes description of the matters which will be covered in the interview. They will reassure you that the interview will not follow any particular script and will just run its natural course. In our experience, this is often not true and usually, the factual interview is expertly conducted in a way to obtain as much information from you as possible, regarding the matters which the insurer is seeking to investigate.
You have rights
Importantly, under the Life Insurance Code of Practice, you have certain rights.
- Firstly, you are entitled to have a representative or support person (including a lawyer) present with you at the meeting.
- Secondly, the interview may not exceed 2 hours unless you agree to an extension.
- Thirdly, you can choose the location of the interview, within reason, and you are not required to allow the interview to be conducted at your home.
- Fourthly, you are entitled to a copy of the transcript of the interview.
- Lastly, the interviewer will usually ask whether they can record the interview. You don’t have to agree to an audio recording but that might mean the interview takes longer and it will mean that you won’t have a recording of what was actually said at some later point in time.
In some cases, you can refuse to attend altogether. We recommend you seek advice from someone experienced in this area of law before you participate in the interview or choose to refuse to participate.
You may also find our article, “5 common tricks and traps when claiming TPD insurance” helpful.
If you have been asked to attend a factual interview with an insurance investigator or any third party during the assessment of your TPD, income protection, trauma or life insurance claim, we recommend that you seek advice regarding:
- whether the request that you attend the interview is reasonable; and
- whether you are able to refuse to attend; and
- what information the insurer has to give you before the interview.
We are experts in superannuation and insurance claims. We conduct all of our investigations for free. If you have a claim, we will act for you on a no-win, no fee basis.
If you would like more advice on the matters outlined in this article, please get in touch directly with today’s blog writer, superannuation and insurance lawyer Tom Cobban.
Melbourne: 03 9448 8048
Brisbane: 07 3013 4300
Anywhere else in Australia: 03 9448 8048
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