q2 2017 claims case study booklet - · pdf fileclaims factsheet & case studies updated...

Claims Factsheet& Case StudiesUpdated February 2018

Individual ProtectionMultiProtect

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1 MultiProtect - Claims Factsheet & Case Studies

MultiProtectclaimsMetLife MultiProtect provides cash payments if you suffer from a specified accidentalinjury, or if you need to spend time in a UK hospital. It also provides peace of mind for yourloved ones if the worst happens.

2017 Claims Statistics

l £7,141,655 million of claims paid out l 878 children’s hospitalisation claims

l 8,899 of claims paid l 105 funeral claims paid

l 4,470 adult and children broken bone claims l 23 child cancer diagnosis claims

l 3,383 adult hospitalisation claims l 15 accidental death claims

We are proud to say we have a claims acceptance rate of 90.3%, and as you can see we have provided extra financial support to our customers when they have needed it most - covering a range of injuries from broken bones to those that have had a significant impact on our customers’ lives.

Top 3 reasons policyholders made a claim in 2017

1. Broken bones (major and minor)

2. UK hospitalisation due to sickness

3. UK hospitalisation due to accident

Main reasons why a claim was not accepted

l Broken bone claims where the treating medical professional did not confirm a broken bone

l Hospitalisation claims that are not covered by the policy (eg. hospitalisation outside of the UK, less than 24 hours spent in hospital)



Feedback from our customers

“The attitude and professionalism of the claims assessor was absolutely amazing, warm and friendly”

“Company is fast, professional, all companies are supposed to be like yours!”

“The claim was made around Christmas. Even with the holidays, it was dealt with quickly and smoothly.”

“I am very pleased and impressed with it. I should have done this a long time ago”

“Great service and a name you can trust”

“My experience with MetLife was awesome”

“I was very pleased with the way my claim was handled and I would recommend MetLife to family and friends”

“It is a good choice for every family with children especially”




Top 10 claims questions

BonesDo you cover stress fractures?

We do not cover stress fractures (a tiny crack in a bone, or severe bruising within a bone) caused byoveruse, mechanical stress and repetitive (rather than sudden) activity. This is because this type of injuryis not caused by an accident.

What happens if a bone is broken again? Will you pay out?

It’s not unusual for someone to break a bone in the same place as they have previously broken it. We will cover a subsequent break as long as it can be proven by medical evidence (e.g. via an x-ray) that the bone had fully healed. If the bone had not fully healed and is broken again it is not covered.

HospitalisationCan I claim for hospitalisation due to sickness?

Yes.TheUK hospitalstay mustbefor24hoursor more and thefirstdateyouareadmittedtohospitalmust be once your policy has been in force for 12 months. You should note that you will not be able to claim if any of the exclusions are applicable such as alcohol/drug abuse, wilful actions or elective cosmetic surgery etc.

Is an unplanned C-Section covered under the policy for hospitalisation?

MultiProtect does not cover claims arising from pregnancy or child birth. We would only consider a claim for hospitalisation whereitisspecifically relatedto treatmentofanynon-pregnancy relatedillness.We will not cover claims for any hospitalisation for the child birth (by C-Section) or new mother checks or illness related to pregnancy.

Claims, claims forms and supporting documentsWho should complete the medical section of the claim form, the GP or hospital?

Thepolicy does not statethatithastobeaspecificdoctor, however, itdoeshave to be adoctor thathas treated you for the injury for which you are claiming. Sometimes your GP may not receive information about your injury until a few weeks after the accident if you initially attended hospital and that is where the diagnosis was made. If you have an upcoming appointment with a specialist before being able to get an appointment with your GP, then it will be quicker to have the hospital complete the

forms.

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What documents are required to support an accidental death claim?

We would need a fully completed claim form with the Form of Discharge completed (both availableonrequest from us). Wewouldalsoneedacertifiedcopy of adeathcertificateandtwoformsofIDforeachof thebeneficiaries.Asthebenefit will be morethan £30,000thenwe wouldalsoneedtoseeacopyofaGrantof ProbateorLettersof Administration. Wherethe deathoccurredabroad,we would also need some additional information regarding the reasons for being abroad and details of foreignhospital/doctors whomayhave treated thedeceased.Payment ofdeathbenefit willbemadein line with the instructions from the personal representatives of the estate as named in the Grant ofProbate.

Child cover claimsWould you consider a claim under Child Cover from the partner of a child’s mother/father?

Yes, as long as the partner has additional Child Cover as part of their policy. We would consider the child/childrenasstepchildrenasper thepolicydefinition of an eligiblechild.We wouldthenconsiderthe claim upon receipt of suitable evidence that they are eligible and fully meet the policy criteria.

What happens if the hospital will not perform an x-ray on a child?

We can accept a suitable clinical diagnosis if no x-ray is available to confirm the diagnosis. We may wantto ask the treating and diagnosing medical practitioner what factors and symptoms led them to a clinical

diagnosis.

Accidents/claimsDoes “loss of finger” have to be the whole finger?

MultiProtect prior to 8 February 2018

Yes, the policy defines “loss of” as being the entire finger, although all claims are assessed on their ownindividual merits, we have to assess claims in line with the policy terms and conditions.

MultiProtect from 8 February 2018

Wherehalfor more thanhalf of therelevantfinger,toeor thumbislostwewillpayaproportionateamountofpolicybenefit,inlinewith the extentof thelossbasedonmedicalevidence.

Are ligament/tendon injuries covered?

MultiProtect prior to 8 February 2018

These types of accidental injuries are not insured events and are not covered by the policy. You may be able to make a claim for hospitalisation if you are admitted to hospital and the stay is over 24 hours. If you have held your policy for less than 12 months we can only consider the hospitalisation as long as the accident leading to hospitalisation happened during the policy term.

MultiProtect from 8 February 2018

Theseaccidental injuriesareinsuredeventsunder theoptional Active LifestyleCover whichcanbeaddedat thestartof your policy.Whetherornot youhave ActiveLifestyleCover youmaybeabletoclaim for hospitalisation as above.

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Contents - Claim case studies

Page

Broken Bone - Cycling - £1,500 6

Broken Bone - Football - £1,000 6

Broken Bone - Car Accident - £1,000 7

Broken Bone - Child - £200 7

Hospitalisation - Stroke - £16,750 8

Hospitalisation - Pneumonia - £8,400 8

Hospitalisation - Pacemaker - £5,500 9

Hospitalisation - Child - £900 9

Broken Bones & Hospitalisation - Car Accident - £24,800 10

Broken Bone & Hospitalisation - Cycling - £1,300 10

Broken Bone & Hospitalisation - Rugby - £1,100 11

Broken Bone & Hospitalisation - Injured At Work - £850 11

Broken Bones, Loss of Organ & Hospitalisation - £40,650 12

Funeral Benefit - £2,500 12

Accidental Death - Factory Accident - £200,000 13

Accidental Death - Motorbike Accident - £50,000 13

Please note that whilst customer names have been anonymised, the following represent real life MetLife case studies. All policies are subject to policy terms and conditions. Exclusions and limitations apply.



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Mr C was out cycling when he was hit by a car and knocked off of his bike. He suffered a break to his wrist. The claim form with supporting medical evidence was received and his claim was paid for one major broken bone.

Case Study

Broken Bone

Cycling

CustomerMr C

Cover3 Units + Child Cover

ClaimBroken wrist

Payment£1,500

Occupation Warehouse operative

Policy start date01.06.2016

Claim submitted 27.06.2016

Payment made 05.07.2016

Mr S broke his wrist (scaphoid) during a tackle when playing football at his local club. There had been a previous break to the same bone, but this was over six months old and there was no evidence of a previous break. We paid out for one major broken bone.

Case Study

Broken Bone

Football

CustomerMr S

Cover2 Units

ClaimBroken wrist

Payment£1,000

Occupation Self employed electrician







Mr S was driving his taxi when he was hit by another car at about 20mph causing him to break his left wrist. The claim was assessed on 25.07.17 and a payment was made the same day.

Case Study

Broken Bone

Car Accident

CustomerMr S

Cover2 Units

ClaimBroken wrist

Payment£1,000

Occupation Self employed taxi driver




The family were on holiday overseas when the daughter (four years old) was playing on a trampoline. The daughter unfortunately fell off the trampoline and broke her right tibia (proximal tibia), so she was taken to A&E where she was treated.

Upon the family’s return to the UK, a claim form was sent to MetLife with evidence of a follow up appointment completed in a hospital. MetLife paid out for a broken tibia.

Case Study

Child Broken Bone

Trampoline

CustomerMrs B

Cover1 Unit + Child Cover

ClaimFractured Tibia (Child)

Payment£200






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Mr S suffered a cerebral infarction (stroke) and had to stay in hospital for 67 days. The claim was submitted on 16.05.17, assessed on 23.05.17 and payment was sent just one day later. Mr S received a payment for £16,750.

Since this incident, Mr S has had to go back into hospital for a related condition. For the second claim MetLife will only ask for a copy of the discharge summary and not a claim form, because the claim is related to the first condition and is considered a continuation claim.

Case Study

Hospitalisation

Stroke

CustomerMr S

Cover5 Units

ClaimHospitalisation

Payment£16,750

OccupationHouse Husband




Mr B was admitted to hospital for 3 months for aspiration pneumonia. Mr B was in hospital for 84 complete 24 hour periods. His claim was assessed and paid within seven working days.

Case Study

Hospitalisation

Pneumonia

CustomerMr B

Cover2 Units


Payment£8,400







Mr B was admitted to hospital on the 01.03.16 due to an infection involving his pacemaker system (endocarditis) and had to be treated with antibiotics directly into his vein (intravenously). He was discharged from hospital on the 25.04.16. Mr B was paid for 55 x 24 hour periods of hospitalisation.

Case Study

Hospitalisation

Pacemaker

CustomerMr B



Payment£5,500

Occupation House Husband




Mrs M’s son was admitted to hospital with hypoxia symptoms (deficiency in the amount of oxygen reaching the tissues). Upon investigation the consultant decided to complete an adenotonsillectony(an operation to remove both the tonsils and adenoids). Mrs M’s son stayed in hospital for 9 days following the operation. The claim form was received on 27.04.17 and after receipt of further required information we paid the claim in full to the insured parent.

Case Study

Child Hospitalisation

Operation

CustomerMrs M


ClaimChild Hospitalisation

Payment£900






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Mr V was driving in Belgium when he hit a parked car at speed. The accident caused Mr V to be trapped in his vehicle and he had to be freed by the fire department. Mr V sustained 8 major broken bones and 4 minor broken bones. He was initially taken to hospital in Belgium and then transferred to a UK hospital where he spent 36 complete 24 hour periods. We verified the accident with the hospital in Belgium and the police force. Once completed we paid Mr V’s claim.

Case Study

Broken Bones & Hospitalisation

Car Accident

CustomerMr V


ClaimBroken Bones & Hospitalisation

Payment£24,800

OccupationVan Driver




Mr D was riding his bike and lost his balance when passing a hole in the road. He fell onto his right hand and broke the radius bone in his arm. He was admitted to A&E and had an operation to fix the break. His claim was assessed and paid for a major broken bone and hospitalisation within 10 days.

Case Study


Cycling

CustomerMr D

Cover2 Units


Payment£1,300







Mr G was playing rugby at an amateur level when he was tackled, his foot remained planted in the mud but his leg twisted with the other player’s weight falling on him. He suffered a dislocated right ankle and a broken fibula (calf bone). He was admitted to hospital the same day as the break required internal fixation and was an inpatient for over 24 hours. We agreed a payment of £1000 for his broken leg bone (£500 per unit) and £100 (£50 per unit) for his stay in hospital.

Case Study


Rugby

CustomerMr G

Cover2 Units


Payment£1,100

OccupationFactory Worker




Mr P was holding a door open at work when a gust of wind blew him over, causing him to break his tibia (shin bone). Mr P was also hospitalised for seven days as a result of his injury. We received the claim form and initially paid for one major broken bone and six days hospitalisation as we were waiting confirmation of the date he was discharged from hospital.Once we received a response from the hospital confirming the exact times of hospital discharge we were able to pay the final period of hospitalisation.

Case Study


Injured At Work

CustomerMr P


ClaimMajor Broken Bones & Hospitalisation

Payment£850

OccupationFactory Operator






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Mr A sadly passed away after suffering from heart disease. The claim was assessed and payment was made to the funeral director within four working days.

Case Study

Funeral Benefit

CustomerMr A

Cover5 Units

ClaimFuneral Benefit

Payment£2,500




Mr D was on a site at work when a colleague accidentally drove a digger into him, which crushed him against a wall. Mr D sustained 3 broken ribs, 3 broken vertebrae and his spleen was severelydamaged and needed to be removed. These injuries were all covered under Mr D’s policy and a payment was made for them, as well as Mr D’s stay in hospital which lasted 35 days. Minor broken bones (ribs x 3) = £900Major broken bones (vertebrae x 3) = £4,500Accidental loss of a major organ (spleen) = £30,00035 complete 24 hour periods of hospitalisation = £5,250

Case Study

Broken Bones, Loss of Organ & Hospitalisation

Injured At Work

CustomerMr D

Cover3 Units

ClaimBroken Bones, Loss of Organ & Hospitalisation

Payment£40,650







Mr X worked in a factory where his job involved using heavy machinery and equipment. Mr X had climbed into one of the pieces of machinery to unclear a blockage, while his colleagues cleared another blockage elsewhere at the factory. After climbing into the machinery, the power was restored and Mr X was trapped in the machine as it began to work again. CCTV showed Mr Xclimbing into the machine and this is where his death occurred. The Coroners verdict was received byour claims team on 12.05.17.

Case Study

Accidental Death

Factory Accident

CustomerMr X

Cover4 Units

ClaimAccidental Death

Payment£200,000

OccupationFactory worker




Mr H was riding his quad bike along a public road. It was a new powerful bike which he had not ridden before. He lost control and came off his bike and sadly died later that day. An inquest was held where it was concluded that Mr H died as a result of traumatic head injuries. The claim was assessed and a payment of £50,000 made.

Case Study

Accidental Death

Motorbike Accident

CustomerMr H


ClaimAccidental Death

Payment£50,000

OccupationFactory worker






Tel: 0800 917 0100 metlife.co.uk/multiprotect

Products and services are offered by MetLife Europe d.a.c. which is an affiliate of MetLife, Inc. and operates under the “MetLife” brand.

MetLife Europe d.a.c. is a private company limited by shares and is registered in Ireland under company number 415123. Registered office at 20 on Hatch, Lower Hatch Street, Dublin 2, Ireland. UK branch office at One Canada Square, Canary Wharf, London E14 5AA. Branch registration number: BR008866. MetLife Europe d.a.c. (trading as MetLife) is authorised by the Central Bank of Ireland and subject to limited regulation by the Financial Conduct Authority and Prudential Regulation Authority. Details about the extent of our regulation by the Financial Conduct Authority and Prudential Regulation Authority areavailable from us on request. www.metlife.co.uk

IP17 00 156 l 2452.03 FEB 2018

Need to make a claim?Call: 01273 872492 or 0800 917 1333 Email: [email protected]



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