Employee Benefits Claims & Servicing

What

As part of the claims process for Group Income Protection schemes, it is important that our claims management team are able to investigate and understand the events giving rise to a claim. They may also be able to provide support for you and your employee to achieve a return to work.

When

• You should notify us when an employee has been continuously absent from work for one month (or has worked on a reduced basis for a period of one month) due to injury or illness. You can notify us completing and submitting our Absence Information Template. We will work with you to consider whether Early Intervention could hep support a return to work.
• If the duration of an employee’s combined absences over the past 12 months  (or if they have been working on a reduced basis for a period) is equal to or exceeding half of the deferred period, you do not need to complete the Absence Information Template, and a formal claim for benefit should be made. 
• This should be done as soon as reasonably practicable but in any event no later than 6 weeks before the end of the deferred period.

How

• Claim forms completed by both you and the employee, including details such as the full duties of their occupation, what is preventing them from working, their salary, etc; and
• A signed and dated claim consent form which allows us to process sensitive personal data and obtain medical reports and information.

Generali will then obtain medical evidence to support the claim, by contacting the employee’s doctor(s) in the first instance. This could include:

• A copy of medical records from the employee’s GP, together with any relevant hospital notes and reports. This should provide us with full details of the medical history and current condition;
• A report from any treating Consultant or Specialist, if appropriate.

We always reserve the right to obtain further independent medical evidence, investigations or examinations if required. Once in receipt of all of the required evidence, we will advise you whether the claim has been accepted and confirm the amount of benefit payable. Benefit is payable monthly in arrears, from the end of the deferred period as specified in your policy schedule. Benefit will continue, subject to regular reviews, until one of the following occurs:

• The employee returns to work;
• The employee reaches termination age;
• The maximum number of benefit payments has been made;
• The employee dies;
• The employee’s membership of the scheme or employment is terminated;
• The employee recovers and no longer satisfies the definition of incapacity;
• There is a breach of the employer or employee’s obligations under the policy.

Who
Once we receive the completed claim forms we will confirm your main claims handler, together with their contact details, so that you can get in touch with us quickly and easily if you have any questions or queries.

Frequently Asked Questions
Where can we get claim forms?
All claim forms are available from the Document Library page of our website.

Does the employee always have to attend a medical examination?
It depends on the individual circumstances of the case. Often the information provided by the employee’s own doctors will be sufficient, but we reserve the right to request further information if we feel it is required to fairly assess the claim.

Who pays for the medical evidence?
When we ask for medical evidence we will pay for it. If the employee is located outside of the UK, we will cover the cost up to the equivalent of the UK cost. Any excess will be your responsibility.

How much benefit will the employee receive?
This varies depending on what level of cover was requested when the scheme was set up. 

Do you make payments directly to the employee?
Benefit is usually paid to you as the employer and you should pass it on to the employee through your normal PAYE procedures.

What happens if an employee receiving benefit leaves our employment?
Payments will cease upon the employee leaving service.

Can a lump sum payment be made?
You may select a benefit design which includes payment of a lump sum however, a typical benefit design provides a monthly benefit. We appreciate that in certain circumstances, a lump sum settlement may be the most appropriate solution for all parties, however this would typically fall outside of the standard terms of the policy and may be discussed and negotiated with your claims handler on a case by case basis.

How often are claims reviewed?
The frequency of review is geared to the individual circumstances of the case and you will be advised when the next review will take place.

What happens if an employee is not fully recovered but returns to work in a reduced capacity?
A partial benefit may be paid at our discretion to support employees in this situation. The level of benefit paid will be such that it is financially advantageous to the employee to return in a reduced capacity whilst maintaining an incentive to return to full-time work. We may also be able to provide rehabilitation support to help with the return to work.

What happens if a claim has been paid but the employee becomes incapacitated again shortly after returning to work?
Provided the new period of absence is within a period equal to twice the deferred period, or 52 weeks if longer, we can waive the requirement for a new deferred period to be served and recommence benefit payments immediately (subject to supporting medical evidence).

Can we appeal if a claim is unsuccessful or we are unhappy with the outcome of a review?
If you are unhappy with the handling of a claim, including any decision in respect of a claim, or if your employee has expressed dissatisfaction, you should direct your complaint in the first instance to our Customer Relations Officer at: Assicurazioni Generali S.p.A, 55 Mark Lane, London EC3R 7NE.

If you remain dissatisfied with the outcome of our investigation, then you may be able to refer this matter to the Financial Ombudsman Service, subject to the jurisdiction of the Financial Ombudsman Service:

The Financial Ombudsman Service
Exchange Tower
Harbour Exchange Square
London, UK
E14 9SR
Phone: 0800 023 4567
Email: complaint.info@financial-ombudsman.org.uk
Website: www.financial-ombudsman.org.uk

Making a complaint will not prejudice your right to take legal proceedings

What

Our clients have access to a wide range of Added Value Support Services including:

• Employee Assistance Programme (EAP) with 6 sessions of face to face counselling and comprehensive online support via mobile app and website;
• Second Medical Opinion (SMO) service (including Mental Health Navigator) from Teladoc Health.
• Eldercare Support Service, unique to Generali UK, aimed at supporting the sandwich generation or those with caring responsibilities. 
• Virtual GP from Teladoc Health
• Comprehensive day zero, early intervention and rehabilitation services.

Offering these additional services to employees can bring many benefits including enhancing health and wellbing, engagement, productivity, loyalty and employee advocay.

How

Promote services using a range of free promotional materials from our Document Library or contact us via eb.enquiries@generali.co.uk to gain access and assistance promoting these valueble services.

When

We are happy to visit clients at inception in order to help promote the Added Value Support Services.

Who

Our Business Development Team are available and would be delighted to assist.

What

To become a Generali client, you or your intermediary needs to complete our 'On Risk' form confirming the reference of the quotation you have accepted and the effective date of cover. An Application Form and an Invoice as confirmation of our required deposit premium will then be sent by us along with the 'On Risk' letter which will also detail any outstanding requirements unresolved from the quotation and request data as at the inception date of your insurance with us.

How

Your inception statement of benefit and cost and your policy schedule will be issued upon receipt of the completed application form, inception data and individual members acceptance terms.

When

It is important to return all of your On Risk requirements as soon as possible, so your policy can be administered efficiently. Delays in the receipt of this information may result in Members not being fully covered for benefits and may affect the settlement of claims.

The Application Form, any outstanding requirements and the deposit premium must be received within 30 days of receipt of our request.

Please note, late payment of premiums may jeopardise claim settlement or result in termination of cover.

Who

You will receive a Welcome Email email from your appointed Account Exective, which will include their contact details, so you can get in touch with us easily and quickly if you have any questions or queries.

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What

Medical Underwriting is the process by which we assess the potential risk of an employee based on factors related to their past and present state of health, family history and lifestyle. This risk will either be classed as:

• Mortality (group life assurance) - those factors potentially affecting life longevity; or
• Morbidity (group income protection) - those factors potentially affecting the likelihood of developing diseases or disabilities.

When

We medically underwrite all employees who are late-joiners or who have salary/benefit in excess of the free cover limit.

Who

If medical underwriting is required, we will provide you with contact details for your designated medical underwriter together with their contact details

How

Each employee that requires medical underwriting will need to complete a personal declaration form. This will ask for medical and family history together with some lifestyle questions and any current or previous medical problems, and must be completed by the employee. The personal declaration form must be completed and returned to us within 30 days. Temporary cover will be provided for benefits that are subject to medical underwriting for a maximum of 90 days from the date of request.

Our Medical Underwriters will assess each personal declaration to determine if we need any further information. This could involve writing to the member's own GP or arranging for an independent medical examination.

Once we are in receipt of all of the required medical evidence, our Medical Underwriters will make a decision, and this could result in one of the following:

• The employee being accepted at ordinary rates;
• An extra premium being charged for the increased risk;
• The employee being declined for cover;
• Cover being excluded for certain activities (in the case of group income protection); or
• Postponement of our decision until a confirmed period of time has elapsed.

We will then notify you of our decision which will be reflected in the statement of benefit and cost issued at the next annual revision date.

When

After going 'On Risk', you may have staff who will need to either join or leave the Scheme at various times throughout the year. In this circumstance, we operate a simplified administration process, ensuring that benefits are covered easily and efficiently.

Who

Your 'on risk' email will have confirmed your designated account handler, together with their contact details, so you can get in touch with us easily and quickly if you have any questions or queries.

How

For those new entrants whose benefit/salary is above the free cover limit or who are joining outside the normal eligibility conditions, we will require the following details:

• Name;
• Sex;
• Date of birth;
• Scheme salary;
• Pensionable salary;
• Level of cover;
• Scheme benefit category;
• Date of joining the company; and
• Date of request for entry into the scheme.

What

Employees joining at their first opportunity who meet the eligibility conditions and whose total capitalised benefit (in respect of group life schemes and death in service pensions) or total salary (in respect of group income protection schemes), is less than the free cover limit, can join without any premium adjustment being made until next revision date of the policy. We do not need to be notified of these employees until that time.

New entrants who satisfy the eligibility conditions but whose salary/benefit is greater than the free cover limit will need to be medically underwritten. We will need to be advised of these employees immediately in order to commence the medical underwriting process. 

New entrants to the scheme who are either not joining at their first opportunity or who you wish to include in the scheme despite them being outside of the usual eligibility conditions, will need to be medically underwritten for their full benefits and they will not be entitled to the free cover limit until they have been medically underwritten and cover has been accepted by us.

For group life assurance schemes, we are prepared to waive the medical underwriting requirements for employees who join more than 12 months after first becoming eligible provided they satisfactorily complete a late entrant form confirming the member meets the following criteria:

• The employee fulfils the 'actively at work' condition on the date they join the scheme;
• The employee's maximum level of total insured cover does not exceed £300,000; and
• The employee has not been continuously absent due to illness or injury for more than 10 consecutive days in the 12 months prior to joining the scheme (including previous employment, if applicable).

For employees leaving the scheme, we only need to be notified at the next annual revision date, unless they are pending medical underwriting. In this case, we will need to be notified immediately so that any medical reports or examinations can be cancelled.

What

The policy normally operates on one year accounting periods. This means we will review the cost of your policy once each year on a specified date chosen by you, we refer to this date as the annual revision date.

Prior to each annual revision date we will notify you of our data requirements and the deposit premium due in respect of the next years cover.

The deposit premium for the next year's cover is based on the current year's unadjusted premium.

When

We will send a letter detailing our requirements directly to you or to your intermediary, if applicable, approximately six weeks prior to the revision date.

It is important that you send accurate information to us as soon as possible so that your policy can be administered efficiently and to avoid delays in medical underwriting.

Payment of your deposit premium must be made within 30 days of the revision date.
Please note, late payment of premiums may jeopardize claim settlement or result in termination of cover.

How

You will be required to provide a list of all members at each annual revision date (and the day before if a premium adjustment is to be calculated) including:

• Name;
• Sex;
• Date of birth;
• Scheme salary;
• Level of cover;
• Scheme benefit category;
• Date of joining;
• Date of leaving if appropriate;
• Details of members working overseas for a period of 12 months or more;
• Details of any members who wish to have cover beyond their termination age; and
• Confirmation that all members are actively at work (subject to specific terms given in your policy schedule).

Should a market review be undertaken please ensure that we are also provided with a copy of the specification and data in order for quotations to be produced on a like for like basis.

If an alteration in the scheme benefit basis is required, then we will need to be notified prior to the annual revision date, as it cannot be guaranteed that such alterations would be backdated.

Once we have received the required data, it will be checked by your main Account Handler and the statements of benefits and costs and an invoice will be sent to you. Any remaining premium will be due within 30 days from receipt of these accounts.

Please note, late provision of complete data may jeopardise claim settlement or result in termination of cover.

What

The premium rate is usually guaranteed for two years, we will then review the rates at the rate guarantee expiry date. However, we reserve the right to conduct an earlier review of the premium rate if there is a significant change in the underwritten risk (for example a large increase in the number of employees to be covered).

When

We will write to you prior to the rate guarantee expiry confirming our requirements.

How

In addition to the standard annual revision requirements, we will require the following information:

• Workplace address for all members including postcode;
• Details of any individual resident abroad as at the annual revision date;
• Details of the individual members occupations; and
• Details of members absent for 90 days or more due to illness or injury at the annual revision date. This should include the member's category of benefit, name, date of birth, gender, the date absence commenced and details of incapacity.

Once all the data has been received, it will be checked by your designated account handler and passed to our scheme underwriting department for review. They will then issue a quotation detailing the terms applicable for the following two year period either to you or your intermediary.

Who

Our revision invitation will confirm your designated account handler, together with their contact details. Once received, the data will be forwarded to our scheme underwriting department and your account handler will provide you with the contact details of the specific scheme underwriter responsible for producing your quotation.

Why us?

We are committed to delivering excellent customer satisfaction. If for any reason you are not fully satisfied with our service, please let us know. Please also consider the added value services outlined in our brochure which include Wellbeing Investment Matching, Eldercare Support, EAP, Best Doctors and a Wellbeing Communication Hub for promoting services to staff.