The assistant group underwriting manager of Universal Provident revealed that 20 per cent of all rejected claims were on these grounds, while 15 per cent of declined claims were due to outpatients claiming on inpatient-only policies.
Other significant factors included whether the treatment was covered by the policy modules selected by the claimant and whether the treatment cost was less than the policy excess.
However, Mr Tranter said brokers and policyholders might be taking more care over claims, as failure to complete or return forms was no longer the main reason for turning down claims, after topping the list in July in last year.
Universal Provident has been revealing its reasons for turning down claims since 2011. Mr Tranter said full disclosure on why claims were rejected demonstrated its ongoing commitment to a “culture of openness” with brokers.
However, Brian Walters, principal of Cheltenham-based health insurance broker Regency Health, said moratorium-based policies were also likely to see more declined claims than underwritten policies, given the lack of clarity over personal medical exclusions.
He added: “There is no pressure on other PMI providers to release declined claim stats, because the data wouldn’t be that meaningful. PMI is so complex that there are many valid reasons why a claim could be declined.”