Does FMI always pay claims?

At FMI, we pride ourselves on maintaining our high claims pay-out ratio, in order to ensure that our clients are covered when they need it most. In 2011 / 2012, our claims pay-out ratio was 98.08%. However, there are instances in which claims will not be paid. While FMI is committed to paying valid claims, claims that are not paid fall into two categories – Repudiated and Not Taken Up (NTU). Repudiated claims: The main reasons for repudiated claims include:

• Non-disclosure of information at initial underwriting stage
• Fraudulent claims
• Pre-existing conditions

Non-disclosure is the most common cause of repudiated claims. It is best to reveal all your historical and current medical conditions at underwriting stage so that we can offer you the best cover for your situation. For this reason, FMI recommends tele-underwriting so that our expert tele-underwriters can source the relevant information directly from you, making things much simpler should you need to claim. NTU claims: A NTU claim is a claim that objectively does not meet the criteria to qualify as a claim. This means that the claimant was not in a position to claim in the first place. Reasons for Claims being classified as NTU include:

• The policyholder no longer wishes to claim
• The disability period is shorter than the waiting period or claimant not booked off work
• Cosmetic procedures that do not meet requirements e.g. elective cosmetic surgery
• Minor infections that do not meet requirements. For certain minor infections, like influenza or bronchitis, you must be hospitalised, go for diagnostic testing, or seek the opinion of a specialist in order to claim
• Claims as a result of drug abuse or alcoholism
• Supporting documents not received

If you need to claim, it is important that you follow the correct claims procedure and supply our Claims Department with the correct documentation. To learn more about our claims process, visit our website or contact our Claims Department on 086 010 1119 or [email protected].