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Claims Case Study:

Updated: Oct 19, 2020

Originally published 5 June 2019

"When I told him we’d got him a positive result, Bill had to just sit down and cry."

This case study comes from AFRM’s Canberra-based Financial Risk Analyst, Justin Beeforth, and it illustrates how our advisers always “go the extra mile” to help our clients in any way we can.

It demonstrates how taking the time to dig a little deeper to fully understand a client’s individual situation can help ensure the best possible claims outcomes.

This story is about Bill [name changed to protect client privacy] who has been a client of AFRM since 2007. Bill is another person referred to us by someone who thought we could help.

Justin took over looking after Bill’s best interests in September 2018, following the retirement of former AFRM Director, Mark Hoskin.

After Bill called to advise AFRM that he had been again diagnosed with cancer, Justin visited Bill at his home to talk through his situation and to see how he might be able to help.

While Bill and Justin were talking, Bill said the insurance companies he had been dealing with seemed to be confused about what “disability” is versus a bout of cancer. Justin promised to fix that issue.

Justin realised Bill’s comment was critical to his current circumstances because Bill’s policy terms allowed for the continuing payment of a benefit until the age of 70 for disability as a result of a traumatic condition.

Bill suffers from a form of B-cell lymphoma that has resulted in him having to file claims on his income protection insurance in response to three separate bouts of cancer over the past decade; from May 2009 to December 2011, from July 2013 to January 2016 and from August 2018 to the present.

Through that period Bill has endured numerous bouts of chemotherapy and has developed a range of varied and complex symptoms that have ‒ in short ‒ made his life hell.

Compounding the disability caused by his symptoms, Bill lost his wife to cancer in 2015 which led to the onset of depression.

Bill is now a frail 67-year-old whose business is failing because he is simply unable to continue to work. He held optimal income protection cover from a major insurer and claimed on it each time he was diagnosed.

Following the chemotherapy treatment for the second bout of cancer, Justin said Bill was “left pretty banged up” by the time he went into remission in Jan 2016.

At the time, his insurer ceased paying out on his income protection insurance on the grounds that Bill had ‘gone into remission’ and could return to work. This was despite Bill still being very incapacitated and not in a fit state to resume working.

Having identified the insurer’s ruling was not consistent with the terms of Bill’s policy, Justin suggested Bill’s GP draft a letter detailing Bill’s medical conditions and symptoms since January 2016 that were ongoing and persistent, irrespective of the cancer remission.

The doctor’s March 2019, letter recorded that Bill had seen him for treatment some 54 times since February 2016, with an average of two to three visits per month.

Among the raft of debilitating symptoms listed by his doctor were severe insomnia caused by serious chronic pain, lethargy and other impairments of motor function that left him incapable of working more than four hours per week, at best.

Bill’s GP concludes:

“In my opinion he remained incapable of sustaining any sort of paid employment throughout this period and remains totally disabled with no prospect of recovery.”

Armed with this new medical report, Justin was able to persuade the insurer to agree to a conference call between the insurer’s Chief Medical Officer and Bill’s haematologist in early April.

On the agenda, was a determination of which symptoms were related to Bill’s cancer treatment ‘hangover.’ The haematologist supported the argument that all of Bill’s ongoing issues stemmed from the impact that the cancer treatment had had on his body.

The call ultimately resulted in a determination that Bill’s ongoing condition was indeed a continuation of the cancer claim that he had been on when his payments had been terminated in 2016, rather than a new claim.

On 17 April 2019, Justin got a call from the insurer confirming they were going to be providing Bill with back pay going all the way back to when they had ceased making payments on his income protection policy back in 2016.

Justin said: “They called to let me know that they’re going to back pay him approximately $8,000 a month (monthly benefit of $7,400 plus premium refund of $600) for the last 31 months. That’s about $248,000.”

“When I told him we’d got him a positive result, Bill had to just sit down and cry.”

When asked how it feels to go into bat for a client and ultimately achieve that kind of a result, Justin’s response was short and sweet:

“It feels amazing mate, there’s nothing like it.”
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