How to make a claim

How to make a claim

Completing claim related forms can be a confusing task especially at a time when you are suffering an injury or sickness. To help support you through the process, on notification of your claim, you will be provided with a dedicated case manager who will be responsible for supporting you through your claim (including helping you complete the claim requirements and answering any questions you may have on the process or status of your claim.)

Do not wait to start the claims process. The sooner we know about your injury or illness, the sooner we can attend to your claim. Even if you have an existing employment process underway or are on leave please let us know. We can provide additional support and assistance through our focus on rehabilitation and get the claim started to facilitate a smooth assessment process.

We are here for you

Your dedicated case manager will also monitor your claim on your behalf and liaise with the Insurer to ensure you receive the right outcome for your situation. The beauty of this is that it is all provided as part of your PSSap membership so any benefit you receive is entirely yours.

CSC’s obligation to our members and claims

CSC, as Trustee of the PSSap, has an obligation to ensure our members are receiving the right outcome from their claims. CSC independently reviews all claims decisions.

The following outlines the process of making a claim:

How to make a claim if you are unable to work due to injury or sickness

How to make a claim.

1

Call us first

Call us on 1300 725 171 to speak to us about making a claim. We can talk you through what is involved and start the claims process for you. To support you through the claims process and make it as easy as possible, you will be provided with a dedicated case manager who will personally oversee your claim and be available to support you if you have any questions.

Your case manager will:

  • be a direct contact for you throughout the claims process
  • monitor and liaise with the insurer about your claim
  • keep you regularly updated on the process of your claim
  • Assist when required to make sure your claim is being assessed efficiently.

2

Complete the paperwork and lodge your claim

You’ll need to complete and submit the forms provided to you in this Claim’s Pack and return everything to us in order for your claim to be further assessed. Your dedicated case manager can help you if you have any questions or are unsure of anything.

3

PSSap will coordinate your claim

Generally, PSSap will be the contact between you and the insurer. We will check your application and provide all of your documents to the insurer. They may, at times, contact you directly to ensure we are dealing with your claim as quickly as possible.

4

The insurer will assess your claim

The Insurer will use the information you provided when making its assessment. They may also ask for more information from:

  • your doctor/s (medical reports etc)
  • your employer (work related duties, rehabilitation etc).

And in order to assess your claim as quickly as possible, they may make an appointment for you to have a medical examination with an independent specialist/s.

5

The insurer will make a decision about your claim

After considering all of the medical evidence and other information, the insurer will decide whether, in its opinion, you have met their requirements to access your benefit. The Insurer will then advise PSSap as to how they have assessed your claim and whether it should be accepted, deferred or declined.

6

Trustee reviews the insurer’s decision

We have a legal obligation to act in the best interests of all fund members and this means that we need to independently review your claim to determine if we agree with decision. If not then we will ask the insurer to review your claim again. Your dedicated case manager will keep you informed along the way.

Where the Trustee and the insurer agree that your insurance claim should be declined, there are also avenues available to you to request another review. Your dedicated case manager can discuss the options available to you at that time.

7

Superannuation decision

Where you are making a claim for a TPD or terminal illness benefit, PSSap will also make a decision about whether your account balance can be released under superannuation law. If your insurance claim is approved, your account balance will also include your insurance benefit.

A lot of the information provided for an insurance claim can be used to make a decision on your ability to access your superannuation, however we may seek additional information.

Income protection claim payments

Where the insurer approves your income protection claim, your benefits will be paid directly to you with a payment of 15.4% being paid directly into your PSSap account while you are recovering. The Insurer will continue to support and directly monitor your progress while you are recovering. You may need to provide ongoing information as part of this process.

How to make a death claim

We understand that coping with the loss of a loved one is a difficult time. We are here to help you through the process of claiming benefits and you will be assigned a case manager to help you through the process.

The process of making a claim is as follows:

What can I expect?

1

PSSap receives notification of a member’s death

2

A PSSap case manager will provide the Death Benefit application form. All potential beneficiaries will complete this form.

3

Completed Death Benefit application form and certified Death Certificate received by PSSap.

PSSap will begin assessment of the Death Benefit application; the assessment will depend on whether or not there was a binding nomination on file.

lifePLUS Cover 

If the late member held lifePLUS cover at date of death, a case manager will lodge an insurance claim and, if approved, the balance will be paid to the late member’s PSSap account.

4

Is there a binding nomination?

No

PSSap will need to ascertain dependants of the late member at date of death and may request further information. The case manager will advise on these requirements through the application.

Yes

PSSap will confirm that the binding nomination is valid and current at date of death and make a payment to the beneficiary/ies.

The insurer will assess the claim

The insurer will use the information provided when making its assessment.

5

The Trustee will make a decision on the payment of the death benefit. All potential beneficiaries will be notified of the decision.

6

Potential beneficiaries will be given 28 days to object to the decision.



Objection  

If an objection is received the case will be referred to the Reconsiderations Committee. All parties will be invited to submit further evidence and we may request further evidence. The Committee will either affirm the decision or make a new decision and all parties will be notified.

Any complaints about the decision of the Trustee, including the Reconsiderations Committee, can be directed to the Superannuation Complaints Tribunal (SCT) within 28 days. No payments will be made until the SCT process is finalised.

7

If no objection is received or if all parties agree with the decision, then payment will be made in accordance with the Trustee’s decision.

Insurance and Super Benefits

For death, terminal illness and TPD claims, the insurance claim is only part of your overall benefit, as your total benefit may also include the early release of your superannuation account balance.

Where you are eligible to be paid both the insurance benefit and your superannuation account balance, we will make a combined payment to you for the insurance claim (excluding income protection) together with the superannuation account balance.

This may take two to four weeks after the insurance decision has been received as we will also need to approve your application for early release. This may take longer for death claims if beneficiaries are still being determined.

Your dedicated case manager will keep you updated as each decision progresses.

You do not need to lodge a claim through a lawyer

The Trustee of PSSap has an obligation to support members through their claim (including making an assessment on whether your claim has a reasonable chance of success).

PSSap offers dedicated case managers who can assist you in completing the required forms, monitor your claim throughout the process with regular updates on progress and chase on your behalf to ensure you get the right outcome. This is all provided as part of your PSSap membership so any benefit you receive is entirely yours.

The beauty of having a dedicated case manager is we can assist through the claims lodgement stage and explain any confusing aspects for no additional cost.

You can always start the process with us and if at any time you feel you need legal advice you can appoint an external agent to act on your behalf. You are not locked into dealing directly with us for the entirety of your claim but it is a good place to start.

Privacy

Your privacy is important to us. Your personal information is collected, held, used, handled and disclosed as required or authorised by law, for purposes relating to managing your super. This includes the management of your insurance cover, superannuation investments, administration of the superannuation schemes and member accounts, and conducting market research and product development. A full copy of our privacy policy is available on our website or call us on 1300 725 171.