Insurance companies have the right to review claims from time to time, to make sure that consumers claiming benefits continue to meet the terms of the policy.
But before an insurance company stops paying a claim, it should explain clearly why it believes that the consumer’s condition has improved – to the extent that they no longer meet the definition of “total disability”.
The insurance company may seek updated medical opinion, or ask the consumer to attend a medical examination. It may also ask the consumer to complete a “continuing claim form”, outlining their ongoing symptoms.
Sometimes insurance companies obtain surveillance evidence showing the consumer carrying out their daily activities. But unless the consumer’s activities – recorded “under cover” this way – are markedly inconsistent with their reported abilities, we are unlikely to place much weight on this type of evidence.
We also expect the insurance company to give the consumer an opportunity to comment on any evidence it obtains to back up its decision to stop paying the claim.
