In force2020 Revised Edition

Contents

Care Shield Life and Long-Term Care Act 2019 · 2020 Revised Edition · Part 6 · Claims and Payouts

16. Claim

(1)

Despite any provision in the Mental Capacity Act 2008, an insured person may receive benefits under the CSHL Scheme or ESH Scheme if any of the following persons makes a claim in accordance with subsection (2) and the Administrator accepts the claim:

(a)

in the case where the insured person lacks mental capacity — an authorised applicant;

(b)

in any other case —

(i)

the insured person; or

(ii)

a person authorised by the insured person to make a claim on behalf of the insured person.

(2)

A claim must —

(a)

be in the form and manner required by the Administrator; and

(b)

be accompanied by any document or information that the Administrator requires to decide whether to accept the claim.

(3)

In deciding whether to accept a claim, the Administrator may —

(a)

carry out such inquiries and investigations in relation to the claim as are necessary for a proper consideration of the claim;

(b)

request that the insured person or claim applicant provide, within a specified time, any additional information that the Administrator requires for a proper consideration of the claim; and

(c)

require that the insured person attend a disability assessment by an assessor.

(4)

The Administrator may refuse a claim —

(a)

if the insured person is not severely disabled;

(b)

if the claim is not made in accordance with this section;

(c)

if the insured person or claim applicant does not comply with the Administrator’s request or requirement (as the case may be) under subsection (3); or

(d)

if the insured person’s severe disability arises from one or more such events or occurrences as may be prescribed.