Universal Provident has become the first private medical insurance (PMI) provider to release details of its paid claims.
Although declined claims statistics have been prevalent in critical illness (CI) and income protection (IP) for several years, health insurers have not yet followed suit.
The provider paid 85.6% of claims submitted between January 2010 and the end of April 2011 with a further 2.6% being paid in part.
Almost half (44%) of those claims declined were for failing to follow general policy conditions.
This was, Universal Provident said, typically failure to follow the claims administration process or pursue the matter after initial notification, but also encompassed self-referring and failure to follow medical advice.
Chronic conditions being the source of claim was the second most declined reason (17.7%), followed by it being subject to a pre-existing condition or moratorium (7.6%) and being a ‘routine' examination (7.6%).
The list was completed by:
• claim falling within the excess amount (6.3%),
• treatment being ineligible given the cover modules selected (5.1%),
• arising from a hazardous pursuit, being cosmetic treatment, a GP service and fertility or infertility treatment (all 2.5%),
• and normal pregnancy or childbirth (1.3%).
Dale Tranter, assistant underwriter at Universal Provident, said: "All of these claims have been declined for perfectly valid reasons.
"We are the first insurer to disclose PMI claims statistics, which is all part of our culture of openness. As far as I am aware, we are also one of only two companies that will disclose claims experience to authorised brokers on request as a matter of course."
