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Case Study

John [name changed to protect client privacy] has suffered from mental health issues over a number of years which have manifested themselves in various ways, including migraine, chronic fatigue, manic behaviour and also, more recently, a formal diagnosis of bipolar disorder.

In 2019, John held a number of insurance policies: retail Income Protection (IP) and Trauma cover, plus Income Protection, Term Life and Total and Permanent Disability (TPD) through one superannuation fund, and Income Protection and Term Life through another superannuation fund.

Due to the nature of his condition, John can easily work one day and be non-communicative the next. It has not been uncommon over the years for AFRM to liaise with John’s parents to obtain information and updates when John is not having a good day.

AFRM’s Claims Manager, Bev Murray, has been John and his family’s key point of contact over the years while managing his claims. To say Bev takes a proactive interest in John’s welfare is perhaps an understatement.

A quick example is, back in November 2018 when Bev and John’s adviser, AFRM Managing Director, Rob Vitnell, came to the view that John’s then ongoing health issues merited investigation of an IP claim (partial disability) through insurance John held through one of his superannuation funds. John had been unable to work full-time for some time.

That led to a months-long series of communications and polite debates with his superannuation fund trustees and the fund’s insurers (…important to note here that the fund’s insurers had changed over the years that John had held his superannuation).

At the crux of the debate was whether or not John was able to make an IP claim on his policy for the same condition he had previously made a claim upon the same policy some years prior. The initial response was that he could not.

AFRM challenged this interpretation because no matter what may have been in the policy wording of the original IP cover provided through his superannuation fund, the current IP policy document, provided by a different insurer, included no wording that stipulated a policyholder could not make more than one IP claim on that policy over a period of time relating to the same condition.

Meanwhile, the insurer contended that while it may not have been articulated, the “intent of the policy” was to provide payment only once per individual condition. It even claimed that that intent had not been properly documented within its own policy.

Again, this position was rejected by AFRM given the policy document itself contained no such wording.

By April the following year, the insurer finally advised AFRM that it had obtained a legal opinion on the matter. That opinion agreed with AFRM that there was nothing in the policy wording saying a policyholder could not claim for the same or a related condition more than once.

Accordingly, a claim was filed and for the following two years (the length of the term of the benefit period) John had been receiving regular monthly IP benefits, assisted by AFRM’s Bev Murray as required.

When the benefit period came to conclusion late last year, Bev reached out to the trustees of his superannuation fund to check on the status of his other policies through fund and made a startling discovery.

“As the IP claim was ceasing because the maximum benefit period had been paid, I wanted to check with the superannuation fund that its ruling around any future IP claims for the same or related condition was still the case. I also checked the level of insurance cover in his other policies through that fund,” Bev said.

“Surprisingly, I was advised that his Life, Total and Permanent Disability (TPD) and Income Protection policies had all been terminated in April 2020 on the grounds that no contributions had been paid into the superannuation fund for the previous 16 months.”

It seems Lloyd had been caught up in the Federal Government’s 2019 Protecting Your Super Package initiative.

The Protecting Your Super Package (PYSP) reforms were focused on member-based funds (not Self-Managed Superannuation funds) and were designed to protect the superannuation savings of Australians from erosion due to inappropriate fees and insurance premiums, as well as reduce unintended multiple low balance accounts.

The reforms introduced the following changes:

  • Insurance became “opt-in” for members whose accounts had been inactive for 16 months.

  • Fund members with balances under $6,000 and whose accounts had been inactive for 16 months had their accounts paid to the Australian Tax Office (ATO). The ATO then consolidated that balance with the members’ active super fund.

  • Fee caps were imposed on certain fees for account balances under $6,000.

  • Exit fees would no longer be charged for moving money from a superannuation account.

The important thing to note here, with regard to John’s case, was that if the policyholder didn’t take proactive steps to opt-in to keep their insurance cover (if they did indeed want to keep that cover) then that insurance cover would be terminated.

When Bev checked in with John about the issue, he was convinced he had indeed filled out the form and emailed it to his superannuation fund trustees, opting in to keep his insurance in his superannuation.

The trustees responded that they had received an email from John (at the time he said he had sent it) but the completed form was not attached. The trustees said they had responded to that email advising John that no form had been attached but never received a reply. So, without any further follow up with John, they cancelled all of the insurance policies under his superannuation.

AFRM took up the fight as soon as these circumstances became clear. After making its initial enquiries on John’s behalf in October last year, AFRM brought the matter to a head by lodging a formal written complaint with the fund’s trustees in March.

“Our argument was that a person who is already on claim receiving a benefit ‒ particularly a person with a mental health disorder ‒ at times cannot keep up with day-to-day simple tasks; he thought he had sent form, but actually had not; but the intent was there as illustrated by the fact that he had sent the email,” Bev said.

“Our other main point was, how can you cancel the insurance cover of a member while that member is actually on a current claim and receiving a benefit from one of the policies in question?”

The complaint also questioned how ‒ when there would have been regular ongoing contact between the fund and its insurer regarding approval of the claim and release of ongoing benefits to John, which would have included an instruction from the insurer to the trustees to suspend monthly premiums while John remained on claim ‒ the trustees could reasonably deem such a superannuation account to be in any way “inactive?”

By late April this year, the superannuation fund trustees responded formally to the complaint in a letter addressed to AFRM’s, Bev Murray.

The response confirmed all of John’s insurance policies had been cancelled because of the introduction of the Federal Government’s “Protecting Your Super” reforms on the grounds that the trustees deemed the account “inactive” because no contributions had been made for 16 months or more.

However, the trustees went on to say that in response to the complaint they had “in good faith” requested the insurer fully reinstate all of Jon’s policies, backdated to April last year.

It is impossible to understate the importance of retaining the protection of both John’s Term Life and TPD policies (each representing hundreds of thousands of dollars in potential benefits) in terms of the financial security they will provide both John and his family.

However, AFRM’s ongoing support of John and his family does not stop there.

Throughout the period that it was fighting to have John’s insurance policies through his superannuation fund reinstated, AFRM simultaneously compiled all of the relevant documentation and filed an IP claim with his retail IP insurer which was also approved.

So, while the benefit period of one of his IP policies has concluded, while he is still unable to return to work full-time AFRM has ensured John is now receiving benefits from his second IP policy.

This is what AFRM means when it says it will always be there to protect the best interests of its clients when they need it most – at claim time.

This is the level of service we are proud to provide to all of our clients.


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