Metropolitan Odyssey, a division of Metropolitan Life Limited An Authorised Financial Services Provider Hereinafter referred to as Metropolitan Odyssey
Claims Guide 7: CU’s QURA Accelerator (QDA)
1. INTRODUCTION 1.1 Explanation of terms 1.1.1 HEC1 = non-RA -single life plans. 1.1.2 HEC2 = non-RA - joint life plans. 1.2 Head Office refers to the Retail Claims at Parc du Cap, Bellville. 1.2.1 ÒClaimantÓ is the person in respect of whom the claim is instituted. 1.3 Claims information is confidential between Metropolitan Odyssey and the claimant and should under no circumstances be divulged to third parties. Please note that Regional Offices have no authority to assess CURA claims. Care must be taken not to create expectations that a claim will succeed. 2. PROCEDURES In case of a claim under the CURA the following procedures should be followed: 2.1 Ascertain the validity of the claim 2.1.1 Ensure that claimant is covered under the policy. 2.1.2 Name and age of claimant must correspond with that of insured. 2.1.3 If there is doubt about the identity of the claimant, obtain proof of identity in the form of identity document, birth/baptismal certificate or sworn statement. If there is still doubt after documents have been obtained, refer to Head Office. 2.1.4 The Lost Policy Affidavit (Form L317) be completed and signed by the policyholder if the policy has been lost. 2.1.5 Check if the premiums have been paid to date. This information may be obtained from Polbrowse. When date of last payment is checked 2.1.6 below should be borne in mind. 2.1.6 Only 30 days grace is allowed for the payment of premiums. If the policy has acquired a surrender value premiums will be paid out of the investment fund. 2.1.7 Take note of all the exclusion clauses applicable (refer to contract). 2.2 Preparing the claim 2.2.1 The completed claim forms are forwarded to Head Office attached to the claims memo L609. 2.2.2 Bear in mind that AIB may be applicable and the amount applicable to the claim may therefore differ from the amount on the policy contract. 3. DOCUMENTS THAT MAY BE REQUIRED Please take special care to ensure that the correct documents are requested. Please refer to Annexure ÒAÓ for a list of requirements for all types of claims. Please note that these are the minimum requirements and that claims department may waive or request additional documents at its discretion. The latest print of claim forms should be used. To ensure that the latest print is used, it is recommended that the forms be printed from the INTRANET (MetWeb). It can be found on the INTRANET (MetWeb) under ÒPick a BusinessÓ/ÒOdysseyÓ/ ÒFormsÓ. 3.1 Policy contract We require the original policy contract in order to settle the claim. If the policy contract is lost, we require a Lost Policy Affidavit. No claim should be forwarded to Head Office without a policy document. 3.2 Medical AttendantÕs Confidential Report (Form L1309) must be completed by the house doctor. 3.3 Specialist Report from the specialist treating the claimant for the condition claimed for. 3.4 Declaration by Employer (Form L1319). This form must be completed by the employer of the claimant and must be accompanied by photocopies of the employerÕs sick leave records. 3.5 Declaration by Claimant (Form L1317) must be completed by the claimant. 3.6 Proof of age If age has not been admitted, we require proof of age. Proof constitutes one of the following documents: 1. Birth certificate
L1420e 11/2006
Co. Reg. No. 1949/032491/06
2. Baptismal certificate 3. Book of life with 13-digit identity number 4. Marriage certificate (provided that it bears the date of birth) 5. Passport 6. If none of the above-mentioned documents are available, a relative older than the insured, e.g. a parent or uncle or aunt, can make an affidavit on which the insuredÕs date of birth is declared. 3.7 NB: The following documents will be required for the following causes of the condition for which the claim is made: 3.7.1 Heart attack: ECG from the treating cardiologist 3.7.2 Stroke: A report from the treating neurosurgeon 3.7.3 Heart surgery: Report from cardiologist/thoracic surgeon. 3.7.4 Cancer: Histology report 3.7.5 Kidney failure: Specialist physician report. The Head Office reserves the right to request any additional information deemed necessary to assess a claim. 4. DISPATCHING THE CLAIM Claims are to be dispatched to Head Office on receipt of all the requirements. 4.1 These benefits work exactly in the same way as CURA. Refer to Metropolitan Odyssey Claims Guides 1 & 3 for explanations, procedures and the claims requirements. 4.2 The only difference to CURA is that QURA covers additional conditions, namely 4.2.1 Major organ transplant Ð Reports from the specialist. 4.2.2 Blindness Ð If due to unnatural causes we require Declaration by Police and Drivers License if Motor Vehicle Accident and claimant was the driver. Reports. 4.2.3 Coma Ð Glascow Coma Scale. If due to unnatural causes Declaration by Police and Drivers License if Motor Vehicle Accident and claimant was the driver. Reports. 4.2.4 Major burns Ð Reports supported by ÒRule of 9Ó of the Lund & Browder Body Surface chart or equivalent classification 4.2.5 Terminal illness Ð Report from the specialist treating L/A for his/her condition (Life Insured suffering from an illness which in the opinion of the Company is likely to result in the death of the Life Insured within 12 months of diagnosis).
Responsible Department: RETAIL CLAIMS Dated: 07.12.2006
L1420e 11/2006