Document ID: chunk:federal_register_of_legislation:F2018L01496:body:0:p22
Version: federal_register_of_legislation:F2018L01496
Segment Type: other
Provision Reference: 
Character Range: 57193–60122

claims:
(a)          The full Sum Insured should be reported here, regardless of whether the insurer made a reduction in accordance with the provisions of the Policy Contract (such as severity-based Trauma or Accidental Injury benefits, DII benefit reductions due to partial disability or a workers' compensation offset, or TPD benefits spread over multiple years).
(b)          In respect of DII claims, the Sum Insured should reflect the monthly benefit under the contract.
66.         In respect of claim outcomes where a benefit was paid, the detail set out in paragraphs 54 to 63 should also be provided for the Claim Amount Paid associated with the claims received. The reporting form should only be completed for the entries associated with a claim payment, namely G.1, G.3 and G.4. In addition, the following should be noted:
(a)          Where a claim is admitted and, consistent with the provisions of the Policy Contract, the Claim Amount Paid is less than the full Sum Insured, the detail should be recorded in the 'Claim admitted (excluding ex-gratia payments)' category.
(b)          For DII, the Claim Sum Insured is the regular monthly benefit that would be paid if the insured were totally disabled and no workers' compensation or other offsets were applied. The Claim Amount Paid should reflect the actual regular monthly benefit payment. In instances where the actual monthly benefit varied over the course of the Reporting Period, an average monthly benefit should be reported.
67.         The detail set out in paragraphs 54 to 66 should be provided for each combination of the following data dimensions:
(a)          Insurance Type;
(b)          On Sale Status;
(c)          Advice Type; and
(d)          Cover/Product Type, including sub-categories.
68.         'Claims Processing Durations' should be reported in respect of Claims Finalised during the Reporting Period, measured as the period between the Claim Received Date and the date the claim is finalised.
    In respect of Cover Types that involve a waiting period, the Claims Processing Duration should be measured from the later of:
(a)          The Claim Received Date; and
(b)          The Claim Event Date plus Waiting Period.
    There are a number of specific circumstances worth noting:
(c)          Where a claim is finalised prior to the expiration of the Waiting Period, a Claims Processing Duration of zero should be recorded; and
(d)          Where a claim is re-opened (subsequent to being withdrawn), the Claims Processing Duration should be measured from the original Claim Received Date and not the Claim Re-opened Date.
69.         Claims Processing Durations should be reported by allocating the number of claims into the following 'claims duration categories':
(a)          0 to 2 weeks
(b)          >2 weeks to 2 months
(c)          >2 months to 6 months
(d)          >6 months to 12 months
(e)          >12 months to 24 months