Claims Case Study:
Originally published on 7 April 2020
“THANK YOU, THANK YOU, THANK YOU!!”
Even highly literate and astute professionals can need assistance handling insurance claims when they fall ill and are not operating at their peak.
That was the case for successful lawyer, 44-year-old, Chloe [name changed to protect client privacy].
Chloe was referred to AFRM by her financial adviser in January 2019 because her claims were complex and her Myalgic Encephalomyelitis (commonly known as Chronic Fatigue Syndrome) was making the process challenging to manage on her own.
Symptoms can include issues with brain function, the gut, the immune, endocrine and cardiac systems.
At the time she came into our care, Chloe was not working due to her illness and was already receiving benefits from a successful Income Protection insurance claim.
AFRM has been supporting Chloe with additional and quite complex Total and Permanent Disability (TPD) and Trauma insurance claims.
Part of the complexity derived from the fact that diagnosis of Myalgic Encephalomyelitis (ME/CFS) is difficult. The condition is not well understood in the general community or in clinical professions. In fact, it is widely misunderstood and finding appropriate treatment and management tools is often very difficult.
Accordingly, AFRM’s support through the claims process included getting additional testing done, exploration of the possibility of obtaining independent or secondary medical opinions, negotiations over the appropriate interpretation of the definitions of levels of disability, including of course, extensive liaison with the insurers and Chloe’s superannuation fund through which the insurance is held.
In April 2019, AFRM was pleased to advise Chloe that her TPD claim was successful, with the insurer paying almost $270,000 into her superannuation account.
At that time Chloe said:
“The help you have given me is way beyond what I expected, and I am very grateful.”
She also recommended our services to ME/CFS support charity, Emerge Australia, and to everyone else she knows.
However, achieving a positive outcome for Chloe’s Trauma claim proved far more challenging.
Two of our Melbourne team members ‒ AFRM Claims Advocacy CEO, Bruno Muraca, and AFRM Advice Associate, Sonal Brar ‒ have been working on Chloe’s behalf since January 2019. Sonal said she has spent so much time working with and supporting Chloe that to say theirs' is a client/service provider relationship does not quite do it justice.
“Despite her ongoing struggle with her health, Chloe is such a positive person and it is always a pleasure to speak to her,” Ms Brar said.
“The amount of times I have spoken to her, she is more like a friend now than a client.”
Upon getting the news her TPD claim had been successful, Ms Brar said Chloe said she felt “lucky” to have found AFRM to assist her.
Meanwhile, Bruno outlined why it took so long to achieve a positive outcome on Chloe’s Trauma claim.
“Chloe’s condition is not widely understood, and the insurer suggested that the Trauma policy did not cover Myalgic Encephalomyelitis,” he said.
“We asked Chloe to get an independent medical assessment done and that too could not unequivocally diagnose the illness.”
“But the fact is, we could recognise that Chloe’s daily living and quality of life was being impacted, so I reviewed her policy and identified that we should relodge her claim, this time based upon the fact that her condition meant Chloe is unable to live independently; without care and support.”
Another medical opinion was sought that validated this argument and that medical report was submitted to the insurer in February this year.
Armed with this new approach, Bruno escalated Chloe’s case to the insurance company’s Chief Medical Officer, highlighting Chloe’s permanent and worsening condition.
Last week, Bruno and Sonal were delighted to call Chloe and share the news that the insurer had now accepted the claim and would be paying a benefit of more than $800,000.
They said they all shed tears during that joyous phone call.
Chloe’s response to Bruno’s follow up email with the insurer’s formal advice that her claim had been accepted was simply:
“THANK YOU, THANK YOU, THANK YOU!!”
The benefit couldn’t have come at a better time. Chloe’s husband had just lost his job due to the COVID-19 pandemic.