24th February 2025

Coma Confusion: Why Claims Need a Second Opinion (And So Do You)

A recent Cover article, “Claims and Underwriting: Claiming After an Induced Coma,” shone a spotlight on two fundamental issues in the protection industry - both of which highlight why financial advisers are indispensable.

Why Every Consumer Needs an Adviser

The first key takeaway is the crucial role advisers play in securing the right protection for clients - and, just as importantly, in supporting them when it comes to claims. Consumers who believe they can navigate the complexities of protection policies on their own - perhaps by using aggregator sites or impersonal call-centre brokers - often learn the hard way that professional guidance is invaluable.

Advisers don’t just match clients with the most suitable policies; they also step in when claims are disputed or misunderstood. Many policyholders, particularly those with critical illness cover, don’t fully grasp what their plan includes. The term critical illness itself can be misleading, implying that only the most extreme conditions qualify - when, in reality, policies often cover a much broader range of medical events. 

When Insurers Get It Wrong

The second major issue is how insurers handle claims. Eighteen months ago, I wrote about my grandson, who was rushed to hospital with a brain abscess. Thankfully, he made a full recovery - but the experience exposed a glaring flaw in the claims process. 

His mother, for whom I had arranged a life and critical illness plan, called her insurer to begin a claim. She rang me back soon after, disheartened - the claims handler had told her that brain abscesses weren’t covered. To “prove” it, they sent her a page from the policy document listing “child-specific” conditions, such as Cerebral Palsy, Cystic Fibrosis, and Muscular Dystrophy.

Unfortunately, the handler had made a fundamental mistake. The child-specific conditions weren’t the only ones covered; they were additional to the standard adult conditions. My grandson was eligible for a claim, but had I not stepped in and spoken to the insurer’s MD, it’s likely it would never have been paid. 

This raised an unsettling question: how many legitimate claims are wrongly denied because of poorly trained staff?

Shortly after, another adviser approached me about a similar case. His client’s critical illness claim had been declined, yet he was confident it should have been covered. A quick review of the policy confirmed he was right. Weeks later, after further intervention, the insurer reversed its decision and paid out.

The Cost of Getting It Wrong

The financial services industry is already battling a trust deficit, and incidents like these only make it worse. While no insurer wants to decline a valid claim, the reality is that errors happen - often due to understaffed claims teams and a reliance on temporary or contract workers. With so many variations in critical illness cover, it’s no surprise that mistakes slip through the cracks.

But this raises an obvious solution: why aren’t all declined claims automatically reviewed by a senior claims manager before a final decision is made? A simple second-opinion system could prevent unnecessary distress, rebuild public confidence, and ensure that policyholders truly get what they paid for. 

At the end of the day, a claim is the moment of truth for an insurance policy. It’s the point at which consumers judge whether their protection plan was worth it. Let’s make sure we don’t fail them when they need it most.

Alan Lakey, CI Expert

Protection