Coverage & Claims Terms
Essential terminology related to insurance coverage provisions, claims processes, and benefit entitlements under Australian life insurance policies
Regulatory Context: Definitions aligned with APRA (Australian Prudential Regulation Authority) and ASIC (Australian Securities and Investments Commission) guidelines
19 terms in this category
Underwriting
The risk assessment process where insurers evaluate an applicant's health, lifestyle, occupation, and financial circumstances to determine eligibility for coverage and appropriate premium pricing. This critical evaluation ensures fair pricing based on individual risk profiles.
Medical Underwriting
A comprehensive health assessment process requiring detailed medical information, examinations, test results, and doctor reports to evaluate an applicant's health risks. This thorough evaluation enables accurate risk pricing and coverage determination based on current health status.
Non-Medical Underwriting
A streamlined assessment process that evaluates insurance applications based on health declarations and lifestyle questionnaires without requiring medical examinations or test results. This simplified approach enables faster policy issuance for standard risk applicants seeking moderate coverage amounts.
Guaranteed Acceptance
Life insurance policies that approve all applicants within specified age ranges and coverage limits without medical underwriting, health questions, or risk assessment. These policies trade simplified access for limited benefits, waiting periods, and higher premiums reflecting unknown risk profiles.
Beneficiary
The individual or entity designated to receive insurance benefit payments upon the insured person's death or specified claim event. Beneficiaries can be nominated through policy documentation or, if none specified, determined by estate distribution or superannuation fund trustee discretion.
Nominated Beneficiary
A specifically identified individual or entity formally designated in insurance policy documentation to receive death benefit proceeds, providing clarity and potentially expediting payment while avoiding estate complications. Nomination strength varies from binding (mandatory payment) to non-binding (guidance only) depending on policy type and documentation.
Death Benefit
The lump sum payment made to beneficiaries or estate upon the insured person's death, representing the core protection provided by life insurance policies. This payment provides financial security for dependents, covering income replacement, debt repayment, final expenses, and future financial needs.
Terminal Illness Benefit
An accelerated death benefit allowing early payout of life insurance proceeds when the insured is diagnosed with a terminal condition expected to cause death within a specified timeframe, typically 12 or 24 months. This provision provides financial support during final months when income ceases and medical expenses escalate.
Total and Permanent Disability (TPD)
Insurance coverage providing lump sum payment when the insured becomes completely and permanently unable to work due to illness or injury, with no prospect of improvement. TPD definitions vary significantly between policies, affecting eligibility and claim likelihood based on occupation-specific or general disability criteria.
Partial Disability
A disability condition allowing some work capacity but with reduced hours or duties resulting in income loss, typically covered under income protection insurance rather than lump sum disability products. Benefits pay proportionally based on income reduction, supporting gradual return to work while managing ongoing limitations.
Claims Process
The systematic procedure by which policyholders or beneficiaries submit, document, and pursue insurance benefit payments following death, disability, trauma, or income loss events. This process involves notification, documentation, assessment, and determination phases, with regulatory obligations ensuring fair treatment and timely resolution.
Claims Assessment
The detailed evaluation process insurers undertake to verify claim validity, confirm policy terms are met, review medical and other evidence, and determine benefit entitlement. This assessment balances thorough investigation with fair treatment obligations under regulatory requirements and industry codes of practice.
Claim Decline
The insurer's decision to refuse benefit payment based on determinations that policy terms aren't satisfied, exclusions apply, non-disclosure occurred, or other valid policy reasons exist. Declined claims can be challenged through internal dispute resolution, AFCA, or legal proceedings, with many decisions overturned on appeal.
Claims Ratio
The percentage of premium revenue paid out in claims benefits, representing a key insurer financial metric balancing sustainability (avoiding excessive payouts threatening solvency) with value delivery (ensuring meaningful benefits reach policyholders). Target ratios vary by product type and insurer strategy.
Policy Exclusions
Specific circumstances, conditions, activities, or causes of death or disability explicitly excluded from coverage under insurance policy terms. These exclusions can be standard (applying to all policies) or specific (applied to individual applicants due to underwriting assessment), and permanently remove coverage for excluded scenarios.
Survival Period
The minimum time period (typically 14-30 days) that an insured person must survive following a trauma diagnosis or event before benefit payment occurs. This requirement ensures permanent impact and prevents claims for conditions that resolve quickly without lasting effects.
Waiting Period
The specified time period at the start of a policy or from the date of disability during which benefits do not pay despite valid claim circumstances. Waiting periods serve different purposes: initial waiting periods prevent immediate claims after purchase (anti-selection), while income protection waiting periods allow short-term sick leave before benefit commencement.
Pre-Existing Condition
Any illness, injury, symptom, or medical condition that existed, was diagnosed, showed symptoms, or for which treatment was received or recommended before the policy commencement date or during applicable waiting periods. Coverage for pre-existing conditions depends on disclosure, underwriting assessment, and policy terms.
Rehabilitation Support
Services and financial assistance provided by income protection insurers to support disabled claimants in recovering functional capacity and returning to work. These programs include vocational assessment, retraining, workplace modification, and graduated return-to-work planning, benefiting both claimants and insurers through improved outcomes.