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Claims Case Study:

“If you don’t ask, you don’t get.”

This case study serves to illustrate the significance of having a highly knowledgeable and experienced professional managing your insurance claim.

It also illustrates the influence AFRM is able to have with insurers at claim time. Namely, persuading an insurer to be flexible in its interpretation of policy terms, even when the client’s medical condition is not listed among the conditions specified in the policy’s product disclosure statement.

And finally, it demonstrates the truth of AFRM Co-founder, Nick Hatherly’s, old saying that:

“If you don’t ask, you don’t get.”

It is the story of Randall [name changed to protect client privacy], a long-term referred client who successfully developed and managed a major engineering business with several partners for more than a decade.

Randall has been the major shareholder of the business and its Managing Director.

By 2020, he’d been a client of AFRM for more than 12 years, with Nick Hatherly as his principal risk adviser.

As is the case with all of AFRM’s clients, Randall received a copy of his Personal Insurance Schedule every year with an offer to review his financial risk management plan if any of his personal or business circumstances had changed significantly.

Accordingly, Randall had refined his insurance cover several times over the course of his relationship with AFRM as his business - and earnings - grew.

AFRM also provided Randall and his business with succession planning advice over the years as the business grew.

Randall held multiple Income Protection and Trauma (Critical Illness) policies, plus also Term Life cover through a Self-Managed Superannuation Fund.

By 2018, Randall’s AFRM advised financial risk management strategy featured:

  • Agreed Value Income Protection cover offering a benefit upon claim of more than $13,000 per month

  • Income Protection (Disability) cover offering a benefit of more than $18,000 per month

  • Trauma (Critical Illness) cover offering a benefit of in excess of $1 million upon successful claim, and;

  • Term Life cover through a Self-Managed Superannuation Fund with a benefit of more than $2.5m upon his death.

In 2019, that foresight and planning was vindicated.

In early April 2019, Randall suffered a haemorrhage of a cavernoma located in his brainstem resulting in his hospitalisation in two separate hospitals for almost a month.

He presented with symptoms including dizziness, numbness of his arms and hands, a strange taste sensation in his mouth and also altered vision.

Never heard of a brainstem cavernoma? Don’t worry. Few people have.

According to metropolitan New York’s, Mount Sinai Health System:

Cavernomas are abnormal clusters of vessels with small bubbles (or caverns) filled with blood that make them look like a berry. These can range in size from microscopic up to several inches in diameter… Since the walls of cavernomas are weak, blood can leak out.”

“Cavernomas can occur in the brain and on the spinal cord. While a cavernous angioma may not affect function, it can cause seizures, stroke symptoms, hemorrhages, and headaches.”

“Approximately one in 200 people have a cavernoma...”

Significantly, it was not among any of the specified illnesses or injuries listed in the terms and conditions of Randall’s Trauma policy. A cavernoma is medically described as a “lesion.”

According to Oxford Languages, a lesion is: “a region in an organ or tissue which has suffered damage through injury or disease, such as a wound, ulcer, abscess, or tumour.”

So, it is described as an abnormal area of tissue inside or outside the body, rather than being defined as an illness or disease in its own right. And being located in the brainstem, it is also not considered a stroke.

Meanwhile, with a prerequisite 13-week wait on Randall’s Income Protection (IP) benefits to come through, AFRM’s General Manager – Client Services, Amanda Anstess, took the lead in immediately commencing the process of preparing Randall’s IP claim paperwork for both of his IP policies.

The Insurer provided the full claim pack on 4 July 2019 and by 10 July 2019 Amanda had filed the full claim paperwork and supporting documentation with the insurer.

This included the completed claim form, discharge summaries from two separate hospitals in which Randall had been treated after the incident, a Medical Certificate from the second of the two hospitals that had treated him and finally a statement from the neurosurgeon that had treated him.

Significantly, Amanda also asked the appointed Claims Manager (at the insurance company) to consider if Randall’s brainstem cavernoma haemorrhage could be considered as a valid Trauma claim against Randall’s Critical Illness/Trauma policy, even though a brainstem cavernoma haemorrhage was not listed among the neurological conditions or cancers covered in the policy’s product disclosure statement.

As is often the case, the insurer requested further information relating to Randall’s treatment and diagnosis in order to progress the IP claim, while the query re the potential for a Trauma/Critical Illness claim remained unanswered for some months.

Meanwhile, Randall had begun to receive his monthly IP claim payments. And his condition had improved sufficiently to return to work for a couple of days a week on shortened hours, even though some symptoms persisted, and his GP had given him a medical certificate stating he was only fit to work these limited hours through to the end of December 2019.

Throughout this period, AFRM’s Amanda Anstess continued to pursue the insurer on its decision relating to the Trauma/Critical Illness claim and the insurer continued to ask for further information or simply did not respond swiftly to Amanda’s enquiries.

By October 2019, Amanda filed an updated claim with additional information requested by the insurer.

The additional supporting information and documentation included:

  • a report from an MRI scan undertaken in June 2019

  • a further report from Randall’s treating neurosurgeon following the June MRI scan

  • a referral from his GP for Randall to see a specialist in Neurological Physiotherapy and rehabilitation in cases of “neurodegenerative conditions.”

  • GP Medical Certificates relating to his incapacity to work full-time through August and September, and;

  • a schedule of exact hours worked since the initial brainstem haemorrhage.

No significant progress was achieved until early January 2020, when the insurer informed AFRM that its own “medical panel” had reviewed the information provided for Randall’s potential Critical Illness claim.

Before moving forward, the insurer's “medical panel” requested a copy of the treating neurosurgeon’s clinical files relating to Randall’s treatment.

Meanwhile, by the end of January 2020, Randall’s condition had deteriorated to the point where he ceased to work completely.

AFRM’s Amanda Anstess continued to follow up and continued, at times, to have difficulty reaching the relevant claims contact at the insurer for an update.

By mid/late February, the insurer provided another update advising that the neurosurgeon’s clinical file had been received and was being reviewed by its “medical team” and an update on the claim outcome would be available “shortly.”

Now that Randall was not working at all and had no regular salaried income apart from his monthly IP benefits, time was of the essence.

By late February, AFRM was advised the insurer’s “medical panel” now wanted to talk to the neurosurgeon in person to ascertain why his June MRI report referred to an earlier brainstem haemorrhage, when in the opinion of the insurer’s medical team such a haemorrhage did not appear to be shown on any of the earlier scans.

By this stage, monthly processing of the separate ongoing IP claim benefits had also begun to slow resulting in Amanda somewhat humorously concluding at least one email to the insurer's case manager with the term “#frustrated.”

In an effort to spark action from the insurer, this same email was then also forwarded by Amanda to the insurer’s Retail Claims Liaison Manager, with whom AFRM had had a long-term good relationship. The IP claims processing issues were immediately rectified.

By April 2020, Amanda was also seeking Randall’s assistance in encouraging his neurosurgeon to remain patient with the ongoing and additional information requests from the insurer in order to expedite, not only his monthly IP claim benefits, but also resolving the ongoing queries the insurer had with various aspects of its ongoing investigation of the pending Critical Illness/Trauma claim.

As we have reported in previous AFRM case studies, it is not uncommon for medical practitioners to lose patience with repeated ongoing information requests from insurers relating to insurance claims. It is a distraction to their day-to-day priority, which is of course providing medical care to their patients.

At this time, the insurer had submitted a list of further questions they wanted the neurosurgeon to provide answers to and the neurosurgeon had acknowledged he had it on his long list of things to do when he could find time in his busy schedule.

This highlights a fundamental challenge in any major and complex insurance claim.

Filling out insurance paperwork to the extent that satisfies an insurance company’s need to thoroughly investigate the circumstances surrounding a claim is simply not part of a medical practitioner's job description. It is an added, externally imposed, administrative burden to be performed in the practitioner’s “spare time”.

Accordingly, Randall personally reached out to the neurosurgeon, apologising for the demands being made upon his time by the numerous insurance company requests being made via AFRM, but also emphasising the importance of the additional documentation from the neurosurgeon to the success of Randall’s claim.

Randall also shared his own frustration at the onerous nature of the claim process in terms of the ongoing requests for further and additional information.

Perhaps understandable, given by this time Randall was routinely attending appointments with various medical specialists to address his various ongoing symptoms. Apart from his neurosurgeon, he was also regularly seeing a neurologist, a stroke rehabilitation specialist, a physiotherapist, a physiologist, an opthalmologist for his affected eyesight, and of course ongoing visits to his GP.

However, AFRM’s Amanda Anstess assured Randall she would not relent in her ongoing drive to expedite a decision from the insurer for his Critical Illness/Trauma claim.

On 1 June 2020, AFRM’s Amanda filed a new set of claim forms with additional supporting documentation with the insurer in a bid to address every possible query the insurer had in relation to the Critical Illness/Trauma claim and listing the ongoing symptoms being suffered by Randall, including tightness in his right leg, tightness behind his eyes, hypersensitivity in his mouth, impaired thinking and cognitive processes, severe fatigue and exhaustion.

By July, Amanda was following up directly with the insurer’s Retail Case Manager, politely highlighting that in AFRM and Randall’s view the insurer’s consideration of the case had been dragging on way too long (for more than a year in total at this point).

It was not until late July 2020 that Amanda finally received informal advice from the insurer that Randall’s Critical Illness/Trauma claim had been accepted.

Formal notification was supplied in writing in early August, confirming Randall had been awarded more than $1.2m as full settlement of his Trauma claim under his Critical Illness/Trauma policy.

Randall confirmed receipt of the funds with a brief note of thanks to Amanda:

“Just to let you know I checked and the money is in my account 😊
“Thank you so much. Talk soon.”

In conclusion, we should note that while this case was indeed complex due to the obscure nature of Randall’s illness/injury, to be fair to the insurer, after extensive research and consideration, it did eventually have the open-mindedness and flexibility of interpretation to agree to pay out on the claim even when a haemorrhage of a brainstem cavernoma was not listed among the neurological conditions or cancers covered in the policy’s product disclosure statement.

This outcome is a testament to Amanda’s dedication and determination in pursuing a positive outcome on Randall’s behalf.


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