What are statements made by the insured in insurance applications considered?

If you disagree with an insurer's decision you will usually need to request an internal review by them within 28 days before you can bring the dispute to us to resolve.

What is it?

An internal review is when an insurer reviews a decision they have previously made about your claim.

The internal review will be conducted by a person with the required skills, experience, knowledge and training, who did not have a role in the original decision. It can result in the decision being changed, or remaining the same.

The reviewer will consider the information used in the initial decision, as well as any further information you provide in support of your internal review application.

Application time limits

You need to make your application for the insurer internal review within 28 days of receiving the insurer decision because late applications may be declined by the insurer.

If the insurer accepts the internal review application, then the insurer will provide the outcome of the internal review within 14 to 21 days. This may be extended up to a maximum of 28 days if further information needs to be requested.

Who can apply for an insurer internal review?

You can apply for an internal review if you are not satisfied with a decision made by an insurer.

General complaints about the insurer, not related to a decision about your claim, will need to be handled as part of the insurer's standard complaints process.

If you are not sure whether your dispute needs to be go to internal review, contact our CTP Assist team on 1300 656 919 or [email protected].

How to apply

Contact the insurer. They may ask you to complete a form and/or provide information supporting your request for review. You can submit any information you think is relevant to the decision being considered, however you should make sure you include:

• why you want an internal review of the decision
• what outcome you are seeking from the review
• what part of the decision you think should be reconsidered (for example, the amount of weekly benefits you receive, and why)
• any additional documents or material you believe will be relevant to the review.

What happens next

1. Contact you: The insurer acknowledge receipt of your application for an internal review within two working days. They will do this in writing, via post or email, depending on your preference.

They are required to explain in detail their internal review process.

2. Carry out the review: The insurer must complete the internal review and notify you of the outcome within either 14 or 21 days of receiving your application. No one involved in the original decision may conduct the review. The internal reviewer may consider additional information that's been received after the decision was made.

3. A decision will be made: On completion of the review, you will receive written notification from the insurer detailing the outcome. The notification must be in plain language and explain how the reviewer reached their decision.

You can call them or us if you need anything clarified.

4. Refer to the Personal Injury Commission if you wish: If you are unhappy with the outcome of the insurer's internal review then you may be able to have the decision reviewed by the Personal Injury Commission. Please see our disputes section to see which matters can be examined by the Personal Injury Commission.

Imagine you bought a second-hand car that came with a dented bumper. When you go to insure it, your insurer will want to know if there’s any existing damage to the car – because they’re not going to pay to fix anything that happened before your cover started. It’s a similar story with life insurance.

When you apply for life insurance, you’re asked to complete a personal statement with a range of questions about your health, pastimes and medical history.

Your completed personal statement is designed to provide the insurer with information to allow them to underwrite the risk of you claiming. The insurer is looking to see if you present a standard risk of claiming or does anything indicate that you have a higher risk including:

• Any pre-existing medical conditions
• Any dangerous pastimes or activities
• Any risky work-related duties

Your insurer needs to know this information because it impacts whether they can offer you cover, what the terms of that cover will be, and how much that cover will cost.

How does this give you certainty?

When you make an insurance claim, the claims assessor will review your medical records to ensure you’ve met your duty to take reasonable care not to make a misrepresentation and you’re eligible to receive a claim.

What if you don’t disclose something?

Not meeting your legal duty can have serious impacts on your insurance. Your cover could be avoided (treated as if it never existed), or its terms may be changed. This may also result in a claim being declined or a benefit being reduced.

Whether we can exercise one of these remedies depends on a number of factors, including all of the following:

• whether the person who answered our questions took reasonable care not to make a misrepresentation. This depends on all of the relevant circumstances. This includes how clear and specific our questions were and how clear the information we provided on the duty was
• what we would have done if the duty had been met – for example, whether we would have offered cover, and if so, on what terms
• whether the misrepresentation was fraudulent
• in some cases, how long it has been since the cover started.

Just because you don’t disclose something or you have made a misrepresentation, that doesn’t mean your claim will automatically be declined.

If your non-disclosure or misrepresentation isn’t related to your claim, and the insurer would’ve still covered you on the same terms if they knew that information, there may be no impact on the claim at all.

However, if the insurer wouldn’t have accepted your cover if they knew that information, your claim may not be paid (read why Steve’s claim was declined). Or if your cover would have been offered on reduced terms, you may receive a reduced payment.

What if it was just an innocent oversight?

There’s a big difference between innocently forgetting to tell your insurer about a medical condition and deliberately leaving something out you know will be relevant to your cover.

When assessing non-disclosure, an insurer will review each case on its merits to establish what is fair and reasonable – taking into account how the non-disclosure came about.

Insurers don’t decline claims lightly.

They’re there to ensure anything relevant to your cover is known from day one, so your policy is tailored to you and fairly priced.

When your duty also applies

Your duty to take reasonable care not to make a misrepresentation also applies when extending or making changes to existing insurance, and reinstating insurance.

What is a statement made in an insurance application?

What does statement mean in insurance?

What are considered to be representations?

When an insured makes truthful statements on the application?