Personal Accident Disability Insurance Claim Guide November Personal Accident Disability

							Personal Accident
Disability Insurance




                Claim Guide




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Information Included in this Guide

     General Information
     How to File a claim
     Additional Documents that may be Required
     The Claims Process
     Limitations and Exclusions
     Rescissions and Benefit Reductions
     How the Advisor Can Help




General Information
We keep the Advisor fully informed so you can help your client through the claims process. You will receive
copies of all correspondence sent to the client.



How to File a Claim
Request a Claim Form
   Insured or Advisor can phone, write or e-mail Manulife Financial to obtain a disability or death claim form (see
   Contact information on Repsource or sellhealthplans.ca). The initial disability claim form is also available in the
   forms section on Repsource or Sellhealthplans.ca.


What we send to the Insured
   The appropriate claim form will be sent together with a standard letter outlining how the form is to be completed
   and any additional documents that may be required.

   We will keep a record of all forms sent out by our office.

   Separate forms should be completed for each claim and claimant.



Additional Documents that may be Required
Along with the fully completed claim form, additional documentation should be submitted in the following
circumstances, if applicable:

   Ambulance benefit - the original invoice for the ambulance service.
   Hospitalization benefit – confirmation of dates of Hospitalization.
   Motor vehicle accident - a copy of the Police Accident Report.
   Accidental Death - a certified copy of the Death Certificate or Funeral Director's Statement.
   Proof of Income - for monthly benefit amounts over $2,000
          Employee: a copy of the previous year’s T4.
          Self-Employed: a copy of the previous year’s tax return including the Statement of Business
          Activities.

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The Claim Process
The claims process starts once the completed claim forms have been received by Manulife Financial.

Claim Entitlement
Manulife will review the claim form and determine:
   Is the client is disabled within the meaning of the policy?
   What was the cause of the disability, Accident vs Sickness?
   What coverage did the client purchase?
   What benefits does the client qualify for?

Additional Information Required
Sometimes it is necessary to obtain additional information in order to make a decision on claim entitlement. This
can occur if:
    the initial claim form has not been completed correctly or completely
    there is conflicting information on the claim form
    there is information disclosed on the claim form that could affect eligibility for coverage
    there is indication that any of the policy exclusions could apply.

If additional information is being requested from any sources other than the claimant, (e.g. doctor, hospital, etc.)
the claimant and Advisor will be informed at the time the information is requested.

Periodic follow-ups will be sent for any outstanding information.

If additional information required is still outstanding after a specific number of follow-ups, this could result in the
termination of a claim.

The Claim Decision
Manulife Financial will make and communicate the decision to the claimant and Advisor within 30 days of
receiving all required documentation on the file.

    If the claim is Approved:
         A claim cheque (and letter if necessary) is sent to the Primary Insured.
    - For a continuing claim, we will outline any future handling of the claim in our correspondence and provide a
         Continuing Disability Claim form, (if required) for consideration of further benefits.
         If no further benefits, the explanation of benefits on the cheque or a letter will indicate that the claim has been
         closed.
         If benefits are not paid as applied for, a letter will be sent to the claimant with the reason why.

    If the claim is Denied:
         A letter will be sent to the Primary Insured outlining the reason for denial.


Limitations and Exclusions
In addition to the terms and conditions of the policy, there are also limitations and exclusions that may affect the
decision on a claim. The client should be fully aware of all terms and conditions, limitations and exclusions before
the decision is made to purchase coverage under the Personal Accident Disability Insurance product line. In
particular, the client should be reminded that the following limitations apply:
         Disabilities diagnosed as a Strain or Sprain - The maximum benefit period is 2 months.
         Disabilities resulting from an Injury to the Neck or Back (aside from a Strain or Sprain, see above) – The
         maximum benefit period is 2 months, however further benefits may be paid if there is evidence of an Injury
         on diagnostic imaging tests.
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Rescissions and Benefit Reductions
Rescissions
A decision may be made during the claims process to rescind coverage under a policy. This occurs when we receive
information at the time of claim that is different from what was disclosed on the application for insurance. The
information must be material enough to have an effect on the insurability of the client in order for the coverage to be
rescinded.

Benefit Reductions
We may determine at the time of claim that benefits should be reduced. Reasons for reducing benefits would include:
         Integration with other sources – this was not taken into consideration when benefits were applied for
         Income is lower than what was stated on the Application for Insurance
         There has been a change in occupation, income or insurance coverage and the client has not adjusted their
         insurance coverage under the policy.
If benefits are reduced, premiums will be refunded for up to 12 months prior to the date of claim.



How the Advisor Can Help
You can help your client through the claims process by:
       Promoting timely claim reporting.
       Emphasizing that the claim form needs to be fully completed
       Reminding the client to include all necessary documentation
       Managing the client’s expectations




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