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How to make a claim

•  Executive Income Replacement Plan

•  Executive Income Protection Plan

Contents

• Introduction
• Step 1 – Making a claim
• Call us for a claims pack
• Complete and return the forms
• Step 2 – Processing your claim
• Gathering and paying for medical evidence
• Step 3 – Assessing your claim
• Your employee’s illness or injury and how it affects your ability to work
• How your employee’s earnings relate to the benefit payable
• Disability Plus
• Paying benefit for a known period of incapacity
• Claims that we do not accept or stop
• Benefit payments
• Reviewing your claim
• Rehabilitation
• Complaints

The purpose of your policy is to provide selected employees with a regular income during a long-term illness or injury that prevents them from working. This monthly benefit is payable in addition to any State benefits that your employee receives. After your employee has been incapacitated for a certain length of time (called the “deferred period” - shown on your Policy Schedule) benefits will start to be paid to you, their employer. Assuming your employee meets the requirements set out in your policy Terms and Conditions, we will pay you benefit until they are fit enough to return to work, until they die, or until the expiry of the policy or benefit term - whichever happens first.

This guide explains how to make a claim, how we will process your claim and what medical or financial evidence we may need. It also describes the role and service provided by our Vocational Rehabilitation Consultants. It is important that you and your employee read this guide in conjunction with your policy Terms and Conditions and Key Features (or Key Facts) document as they cover, in more precise detail, what is and is not covered. If you do need any further information or assistance, please do not hesitate to contact us on 01306 887766 and ask for the claims department. You may also call us at any time to check on the progress of your claim.

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If you need to make a claim, the first step is to contact us on 01306 887766. To help you through the process, we will assign a Claims Management Specialist to look after your claim. They will send you a claims pack for completion by you, your employee and their General Practitioner. They will also contact you or your employee if we need any further information, and will be on hand to answer any questions you or your employee may have. Please note that we will respect your employee’s right to confidentiality at all times.

It is very important that we receive your completed claim forms well before the end of the deferred period (shown on your Policy Schedule). This will help us to make an immediate review of your employee’s situation and start the assessment process.

Ideally, we would like to receive your claim forms within:
•  2 weeks of becoming incapacitated if the deferred period on your policy is 4 weeks;
•  4 weeks of becoming incapacitated for deferred periods of 8 and 13 weeks; or
•  10 weeks of becoming incapacitated for longer deferred periods.

If you delay submitting your claim forms we might not be able to pay your claim on time, as the later your claim is submitted, the more difficult it is for us to collect the medical evidence we need.

Please note that under the terms of the policy, we are entitled to refuse applications for benefit where claim forms are received more than 90 days after the end of the deferred period. The claims pack consists of the following forms:

Benefit Application Form: This form asks for your employee’s personal details, together with details of their illness or injury. Also included is the Claims Processing Consent form, giving us their permission to obtain medical evidence, including copies of their medical records.

Occupational Questionnaire: This asks for details of the occupation your employee was following immediately prior to their illness or injury. You (their employer) will need to complete this form and return it to us.

Medical Summary: This is a form that your employee will need to ask their General Practitioner to complete and return to us. We may also ask for a medical examination or functional capacity assessment, prepared by a specialist who has not previously treated your employee. A functional capacity assessment is an objective measure of an individual's ability to perform a series of activities including lifting, reaching, stretching, standing, kneeling and walking. The tests are designed with your employees safety in mind and they will not be asked to do anything which may cause discomfort.

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We will process your claim as soon as we receive the completed claim forms. However, as you will appreciate, we have to rely on people in the medical profession to reply promptly and collecting all the medical evidence can take some time. Unfortunately, we do sometimes encounter delays in obtaining all the information we need.

If your employee is receiving specialist care from a Consultant, we may ask them to provide us with detailed information from their case notes. If the Consultant has not seen them recently, or the medical evidence is not conclusive, an examination may be required either by their Consultant or an independent Medical Examiner who will be appointed by us. In the event that we do ask them to have a medical examination and/or a functional capacity assessment, we will choose an appropriate specialist, who has not treated them before, to undertake the examination and/or assessment. Please note these reports are not covered by the Access to Medical Reports Act 1988. This means that the information received is confidential to the examiner and to us. However, your employee may ask to see the report, in which case we will send a copy to their General Practitioner, who will be able to discuss it with them. We pay the fees for all the medical information that we have asked for, whether this is at the initial assessment of your claim or at a later review. We will also reimburse any reasonable costs incurred by your employee if we ask them to attend an examination by a specialist.

When assessing your claim we will consider the nature of your employee’s occupation immediately before their illness or injury occurred. “Occupation” means the commonly performed duties of the trade or profession usually undertaken in such a job, rather than the specific duties of your employee’s personal role, and is not restricted to one place of work. We will use all the medical evidence available to determine how their illness or injury affects their ability to follow their occupation. It is important to note that diagnosis of a condition does not necessarily mean that they cannot follow their usual occupation. We will then determine whether their duties could be reasonably modified or omitted in order to allow them to continue working. Please note that employers are now obliged under the Disability Discrimination Act 1995 to provide reasonable adjustments in the workplace to enable employees to continue working if they suffer from an illness or injury. At this stage we decide whether or not to accept your claim.

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Your policy is designed to help replace the earnings of an employee while maintaining a sufficient incentive for them to return to work. For this reason your policy has a Limitation of Benefit clause, which allows you a maximum benefit of 75% of their gross earnings before tax in the 12 months prior to their illness or injury, less the State Long- Term Incapacity Benefit for a single person. Gross earnings are explained in greater detail in the Definitions section of your policy Terms and Conditions. We then deduct the following from the benefit:
•  Other sickness or accident policies held by your employee where benefit is payable for more than two years
•  Income they continue to receive from any trade or profession, or
•  Any Early Retirement Pension they receive as a result of their illness or injury.
Please note that an Early Retirement Pension would not be deducted from the total if we consider the employee to be totally and permanently unable to follow any occupation.

If the insured benefit shown in your Policy Schedule is higher than the maximum benefit allowable, the claim payment will be reduced to the maximum benefit figure. If the benefit insured is lower than the maximum benefit, the payment will be limited to the benefit insured. We therefore recommend that you review the cover with a Financial Adviser regularly. This not only ensures that the benefit provided by the policy is appropriate in relation to your employees earnings, it also ensures that you do not pay a higher premium than you need to.

Disability Plus

If you selected this option for your employee when you started your policy, and you have been receiving benefit continuously for 2 years or more, you may be eligible for this additional benefit. To qualify you need to demonstrate that their illness or injury stops them from doing a number of specified day-to-day activities. These activities are documented in your policy Terms and Conditions. If this option was selected at the start of the policy, we will automatically send you a questionnaire to establish whether your employee is entitled to this benefit when we review your claim.

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If we do not accept your claim or stop it, we will tell you and explain why. Our letter confirming the decision will also include details of the appeals procedure. Our Chief Medical Officer may also write to you and your employee’s General Practitioner explaining the reasons for our decision. Please note that we will respect your employee’s right to confidentiality at all times.

Benefit is always paid to you (the employer) one month in arrears. You should then make corresponding payments to the employee through your payroll (PAYE) system, where appropriate deductions for Income Tax and employee National Insurance contributions will be made. If you have also insured employer’s National Insurance, pension and approved life insurance contributions in respect of the employee, you should also deduct these from the benefit before paying it to them. The first benefit payment will be paid by cheque and all subsequent payments will be paid directly into your bank account.

All claims are reviewed from time to time. If your employee’s medical condition is expected to improve within a certain time, then the review will be carried out during this time. When we review your claim we will normally send you a new claims pack to complete. We may also request further information from your employee’s Consultant or General Practitioner to support the review. In some circumstances their Consultant may wish to see them again. We may also request a further medical examination or functional capacity assessment by our chosen specialist if we think this is necessary.

Our expert Vocational Rehabilitation Consultants may be able to help your employee in their efforts to get back to work, either in their own occupation or in a suitable alternative. Although they may not be able to resume their original occupation on a full-time basis, they may recover sufficiently to be able to work part time. Alternatively they may be able to take a different job on lower earnings. In these circumstances a proportionate benefit will be payable, so they do not suffer financially as they make a step towards rehabilitation. Precise details of how we calculate proportionate benefits can be found in the Benefits section of your policy Terms and Conditions. It is very important when benefit is being paid on this basis that you tell us about any increases or reductions in your employee’s earnings, so benefit can be adjusted before incorrect payments occur.

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If you are not satisfied with the way in which we have handled your claim then please write in the first instance to:
Head of Customer Care Services
Milton Court
Dorking
Surrey
RH4 3LZ

If you are not satisfied with our response then you can complain to:
Financial Ombudsman Service
South Quay Plaza
183 Marsh Wall
LONDON
E14 9SR

About Unum

Unum is the UK’s leading provider of income protection insurance, with over 35 years of experience.

We enable individuals to protect their lifestyles, ensuring their financial security if they become unable to work because of illness or injury. In addition, our income protection customers benefit from our expertise in the specialist areas of vocational rehabilitation and return-to-work. For employers, we safeguard one of their most valuable resources by helping employees return to work following long-term absence.

At the end of 2006, Unum protected almost 2 million people. During 2006 we paid total benefit claims of £285 million – of which more than £191 million related to income protection benefits.

Our US parent company, Unum Group, traces its history back to 1848 and is today the market leader of group and individual income protection insurance in the United States. Premium income for Unum Group and its subsidiaries exceeded $7.9 billion in the year ended 31 December 2006. Total assets were $52.8 billion at 31 December 2006.

For more information please visit www.unum.co.uk

Unum Limited, is authorised and regulated by the Financial Services Authority.
Registered in England 983768.

Registered office:
Milton Court, Dorking, Surrey RH4 3LZ.
Tel: 01306 887766
Fax: 01306 881394
Textphone: 01306 887784

We monitor telephone conversations and e-mail communications from time to time for the purposes of training and in the interests of continually improving the quality of service we provide.

UP916 08/2007

Copyright © Unum Limited 2007

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