1. ANALYSIS
(Part two)
TEAM MEETING
8th MAY, 2017

2. We noted last week that a lot of claims are being repudiated.
Our focus for this week will be on reasons why a lot of claims are repudiated.

3. REASONS FOR REPUDIATION PRODUCT ANALYSIS
LADYCARE
FIPP
TOTAL
CONTINGENCY NOT COVERED 31 2 33
FRAUD 1
NON DISCLOSURE 5 10
BENEFIT WAITING PERIOD NOT DONE 3
POLICY LAPSED AT DEATH
UNISSUED POLICY
CLAIM BEFORE ACCEPTANCE DATE
AGE ABOVE COVERABLE LIMIT
POLICY NOT INCEPTED
EXCLUSION
OTHER 43 15 58

4. CONTINGENCY NOT COVERED
On LAYCARE a lot of claims are filled for contingencies that are not covered by the product. Some of which are:
UTERINE FIBROID
ABDOMINAL PAIN
BREECH BIRTH
SEVERE MALARIA hos
NO TRACE OF MALIGNANCY
PREMATURE RAPTURE OF MEMBRANE
CAESAREAN SECTION (CS)
HERNIA SUGERY
LEG INJURY
NULLIPAROUS
PROLAPSED INTERVERTEBRAL DISC
UTERINE CONTRACTION
TUMOUR WAS REMOVED
ANGINA PECTORIS AND PELVIC INFLAMMATORY DISEASE
BREAST LUMP
FIBROID

5. COVERABLE CONTINGENCIES
On LAYCARE we cover the following based on Enterprise Life’s definitions:
CRITICAL ILLNESS (100% BENEFIT)
BREAST CANCER
OVARIAN CANCER
UTERINE CANCER
CANCER OF VULVA & VAGINA
CERVICAL CANCER
CANCER OF THE FALLOPIAN TUBES
SYSTEMATIC LUPUS NEPHRITIS
CRITICAL ILLNESS (50% BENEFIT)
HEART ATTACK
STROKE
CORONARY ARTERY BY-PASS SURGERY
LOSS OF SPEECH
BLINDNESS AND MAJOR BURNS
SOLID CANCER
PARALYSIS
MAJOR ORGAN TRANSPLANT

6. COVERABLE CONTINGENCIES; LAYCARE
HOSPITALIZATION BENEFIT covers:
BREAST CANCER
OVARIAN CANCER
CERVICAL CANCER
UTERINE CANCER
CANCER OF THE VULVA & VAGINA
CANCER OF THE FALLOPIAN TUBES
RHEUMATOID ARTHRITIS
OSTEOPOROSIS
URINARY INCONTINENCE REQUIRING SURGICAL REPAIR
MATERNITY COMPLICATIONS covers:
ECTOPIC PREGNANCY
MISCARRIAGE DUE TO ACCIDENT
PRE-ECLAMPSIA
DISSEMINATED INTRAVASCULAR COAULATION
FEMALE RELATED ILNESS covers:
RHEUMATOID ARTHRITIS
OSTEOPOROSIS
URINARY INCONTINENCE REQUIRING SURGICAL REPAIR

7. COVERABLE CONTINGENCIES; EFIPP
We cover the following based on Enterprise Life’s definitions:
STROKE
HEART ATTACK
CORONARY ARTERY DISEASE REQQUIRING SURERY
HEART VALVE REPLACEMENT
SURGERY OF THE AORTA
VALVOTOMY
CORONARY ANGIOPLASTY AND STENTING
SOLID CANCER
PARALYSIS
MAJOR ORGAN TRANSPLANT
MAJOR BURNS

8. NON-DISCLOSURE
Non-disclosure of preexisting conditions of Policy Holders is also one of the reasons why claims are repudiated.
Some of the pre existing conditions that are confronted by the Claims Department are:
LET YOUR CLIENTS DISCLOSE PRE-EXISTING CONDITIONS FOR THEIR OWN BENEFIT AND YOUR BENEFIT.
Known
SICKLE CELL
ISCHEMIC STROKE
IMMUNOSUPPRESSION
HYPERTENSIVE
BREAST CANCER

9. LET YOUR CLIENTS DISCLOSE PRE-EXISTING CONDITIONS FOR THEIR OWN BENEFIT AND YOUR BENEFIT.
ALSO MAKE IT YOUR BUSINESS TO LET YOUR CLIENTS KNOW THE COVERABLE CONTIENCIES AND MOST OF ALL THE NON-COVERABLE ONES