Document ID: chunk:federal_register_of_legislation:F2018L01496:body:0:p21
Version: federal_register_of_legislation:F2018L01496
Segment Type: other
Provision Reference: 
Character Range: 54447–57459

undetermined at the end of the Reporting Period, split by Claim Incidence Year (labelled H).
61.         Claims declined (with no payment) should be split between the following categories:
(a)          'Contractual definition not met (including eligibility criteria)' (labelled G.2.1). These are instances where the claimant does not meet the requirements of a qualifying claim, as defined in the Policy Contract. Also included here are eligibility criteria, such as being actively at work, a common requirement for Group Insurance contracts.
(b)          'Exclusion clause' (labelled G.2.2). These are instances where claims are declined on the grounds of a pre-existing condition exclusion, a limited cover clause, an exclusion imposed during initial underwriting, or any other policy exclusion in the Policy Contract. This includes the exclusion clauses that may be contained in the standard policy wording.
(c)          'Innocent non-disclosure or misrepresentation' (labelled G.2.3). Where the claim is declined for reasons of non-disclosure or misrepresentation as contemplated in section 29(1) of the Insurance Contracts Act 1984.
(d)          'Fraudulent claim (including fraudulent non-disclosure or misrepresentation)' (labelled G.2.4). Where a claim is declined on the grounds of fraud or fraudulent non-disclosure or misrepresentation as contemplated in sections 56, 29(2)-(3) of the Insurance Contracts Act 1984.
(e)          'Other reasons for being declined' (labelled G.2.5). Any other reasons for a claim being declined.
62.         Claims incorrectly opened due to an administrative error should be excluded.
63.         Ancillary Benefits that result in an enhancement to the underlying product or cover, as listed in paragraphs 16 to 18, should be included. The inclusion of Ancillary Benefits should, however, not result in multiple claims being recorded in respect of a single Claim Event. Where the payment frequency of an Ancillary Benefit differs from that of the main Policy Benefit (e.g. a lump sum Ancillary Benefit on a DII contract, or a recurring Ancillary Benefit on a lump sum contract), the Ancillary Benefit should be excluded.
64.         The reporting form will automatically calculate 'Claims Open for Assessment in period' (labelled F) as the items reported in accordance with preceding paragraphs 54 plus 56 plus 57 minus 58. In addition, the form will perform a check to confirm reconciliation of the various items of entry. It is expected that F minus G minus H should equal zero.
65.         The detail set out in paragraphs 54 to 63 should also be provided for the Sum Insured associated with the claims received (i.e. Claim Sum Insured). Note the following in respect of Trauma, Accident, DII and TPD 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