Insurance World

Recent stories in the press have again lambasted the insurers over critical illness insurance. The core problem is that a critical illness claim is not as straightforward as, for example, a claim under life insurance. With life insurance it’s going to be hard for the insurance company to argue that you’re not dead!

By their very nature, critical illness claims are much more complicated. The insurer will need to satisfy itself that the claim is validated in three key areas before it meets the claim: -

Has the illness been correctly diagnosed?

Is the confirmed illness included in the schedule of insured critical illnesses covered by the policy?

Did the policyholder fully disclose their medical history and current state of health on their original application form?

On the first point, it’s obviously in the policyholder’s interest to verify the medical diagnosis - so there’s rarely ever any conflict between the insurance company and the policyholder on that issue. It’s the next two areas which the insurer needs to validate, where conflicts seem arise.

With constant development in the medical knowledge, from time to time there can be some situations where validation falls into a grey area – a policyholder will argue that their specific illness is insured whereas the insurer will argue that it isn’t. Insurance companies are aware of this problem and they often change the wording in their policies in an attempt to clarify the scope of the cover and eliminate areas for dispute. Nevertheless, disputes do happen all too frequently and sparks fly when a policyholder thinks his illness is covered but the insurer disagrees.

A case in point comes before the Courts shortly. Mr Hawkins from Staffordshire is suing Scottish Provident for Ј400,000 under the terms of his critical illness policy. Basically, his medical advisers believe his illness is insured whereas the insurers’ medical advisers disagree. If the Court find in favour of Mr Hawkins the press will have a field day - and the critical illness insurers will suffer further bad press they can sorely afford.

Another summons, filed recently in the High Court and again involving Scottish Provident, highlights the problem when an insurer considers that a claimant mislead them on his or her original application form. Our understanding is that if an applicant omits relevant information or provides misleading information on their application from, this amounts to obtaining insurance on false pretences. This summons has been issued on behalf of Thomas Welch from London who is suing Scottish Provident for Ј206,800. The issue goes back to 2000 when, a few years after first starting his critical illness policy, Mr Welch received confirmation that he was suffering from testicular cancer. The insurer refused the claim because of “non-disclosure alleging that Mr Welch had not been honest about his smoking habit. He does admit that he did smoke earlier in his life but is resolute in saying that he had long since given up when he applied for critical illness insurance. As such, Mr Welch believes that he did complete the application honestly.

We assume that the case will centre upon whether Mr Welch accurately answered the smoking questions on his application. Most insurers define “a smoker” as someone who has smoked, or has otherwise used, nicotine products within the previous 5 years. (Some insurance companies adopt a 1year cut off.) If Mr Welch had indeed smoked during the specified years, he would have been obliged to disclose such information on the application and the insurer would have priced his insurance accordingly. In this context, it is relevant to note that smokers are charged as much as 65% more for critical illness over than non-smokers. We anticipate that Mr Welch’s lawyers will argue either that he did not smoke during the period in question or he omitted the smoking information by pure oversight and in any event, his past smoking is not irrelevant to his testicular cancer. Interesting issues and we’ll let you know the outcome.

Mr Hawkins case is fundamentally different. It illustrates the problems that can arise if policy documents imprecisely describe an illness or if the technical diagnosis of an illness provides the scope for medical professionals to disagree. Either way the issues are entirely outside the policyholders control at a distressing time for them and their families and we must appreciate their anguish. The long-term solution must lie in improving the medical definitions within the policy. It is probable that this will result in more medical jargon that the average man in the street will find difficult to understand - but perhaps that is preferable to what Mr Hawkins is going through.

Mr Welch’s court case must stand as a clear reminder to everybody that applications for insurance must always be totally accurate and completed in good faith. We recognise that in some cases this may still leave room for dispute (and Mr Welch’s case may be an example), but if an applicant fails to complete the forms accurately, they are taking the great risk and any claim they make could be rejected.

Rightly or wrongly, the newspapers have a history of giving the insurance companies a hard time, casting them as heartless big business. This serves to reinforce the public’s feeling that insurance companies are devious and not to be trusted - especially it seems, in respect of critical illness insurance. This view is reinforced by the fact that around 20-25% of critical illness claims are rejected (although this rejection rate does vary between insurers). This issue is something that insurers must come to grips with – it’s bad for clients and undermines confidence in insurance - and that must be bad for the development of the insurance industry.

In fact to put no finer point on it, it’s a tragedy. As many as 1 in 6 women and 1 in 5 men will be diagnosed with a critical illness before their normal retirement age*. As such, critical illness insurance is vastly important for the protection of family finances. The problems we have highlighted are obviously contributing to a situation where almost everybody needs critical illness insurance, but fewer and fewer of us are taking it up.

(* Source: Munich Re.)

About 87 percent of the residents of Germany have statutory health insurance, i.e. GKV. As of May 2005, the GKV relied on 321 non-profit sickness funds to collect premiums from their members and pay health care providers according to negotiated agreements. Those who are not insured this way, mainly civil servants and the self-employed, receive health care through private for-profit insurance.
An estimate of 0,3 percent of the German population (around 250,000 people) has no health insurance at all. Some of them are so rich that they do not need it  but most of them are poor and receive health care through social assistance.
Statutory health insurance
There are three different categories of sickness funds: primary funds, substitute funds and “special” funds. Some workers are required to be members of the primary funds, e.g. if they earn less than the than the income ceiling (2006: EUR 3,937.50 per month / EUR 47,250.00 per year). Those earning more than that ceiling may be members on a voluntary basis, or they may have a choice of funds. Some of them automatically become members of a particular fund for example because of their occupation (company-based funds) or place of residence (local sickness funds). Some occupations have their own “special” funds, e.g. farmers or sailors.
Substitute funds are divided into two kinds: they provide health insurance to both white collar workers and blue collar workers earning more than the income ceiling. Membership is voluntary.
Both, employers and employees pay half of a member’s premiums, which in 2006 averaged between 13 and 14 percent of a worker’s gross earnings up to the contribution assessment ceiling (2006: EUR 3,562.50 monthly / EUR 42,750.00 p.a.). Premiums are fixed according to earnings rather than risk and are unaffected by the respective member’s marital status, family size, or health. Premiums are the same for all members within a particular fund with the same earnings.
Private health insurance
About eleven percent of Germany’s residents pay for private health insurance provided by some 40 for-profit insurance carriers. Many of those choosing private insurance are civil servants who want to secure percentage of their medical bills not covered by the government. Some sickness-fund members buy additional private insurance to cover such extras as a private room or a choice of physicians while in a hospital. Otherwise, the medical care provided to the publicly and privately insured is identical. In both cases the same medical facilities are used. Self-employed persons earning above the income ceiling must have private insurance. Members of a sickness fund who leave it for a private insurance carrier are not allowed to return to public insurance.
As opposed to the statutory heath insurance, contributions to the private insurance depend on the member’s age, gender, occupation and health status, that is, the individual risk. Although private insurance companies pay health care providers about twice the amount paid by the primary sickness funds, private insurance is often cheaper than statutory health insurance, especially for younger policyholders without dependents. As is the case for members of sickness funds, employees who have private insurance have half their premiums paid by their employers.