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The onus of proving an exclusion rests with the insurer, the claimant having proved that the insured event, i.e., death of an insured life, has occurred.

Insurers create the contract language in policy terms and conditions, and this includes the actual wording of exclusions. Herein lies our first challenge – the wording of many suicide exclusions tends to be one-dimensional in that it focuses on “suicide” only. The following examples will look familiar to most of us: “Death as a result of suicide will not be covered,” or “A claim will not be admitted if the life insured commits suicide within X years of the policy commencing.” Many variations of such wording exist in insurance contracts, and while they may have been fit for purpose and created with the right intent when initially designed, over the years we have all experienced the challenges of failing to receive a clear cause of death that refers to suicide explicitly.

In the absence of policy wording that is broader and inclusive of scenarios of self-inflicted cause of death, the claims professional will face a great challenge to prove the exclusion wording contained in a contract. Wording such as this: “The policy will be cancelled if within X years of the policy, the life insured dies as a result of suicide, intentional and serious self-injury or an event, wherein the Insurer’s reasonable opinion, the life insured took their own life,” may be more appropriate to our current environment. Other examples include “death by own act, whether insane or not,” or “death is self-inflicted or is due to suicide or assistance suicide.”

As with most policy terms and conditions, such exclusion wording should be reviewed on a regular basis to ensure continued relevance, providing intended protection to the insurer while being fair, clear, and transparent to customers.

For more on this topic, explore the companion case study  Suicide Prevention Initiatives.

Regulations and medico-legal procedures – determining cause of death

Claims professionals must have a sound understanding of the various jurisdictions in which they review and adjudicate claims, bearing in mind that these may vary between states and regions within a particular country. Each country will have a well-defined medico-legal and forensic deaths process that stipulates the procedures involved in certifying a death, including the cause of death. A good understanding of the categories of cause of death, how cause of death is determined and recorded, and what evidence is made available for insurers to receive as claims proofs should be considered when designing exclusion wordings and claims processes.

A few examples where country regulation and customs may have a material impact on how a cause of death is determined and recorded include:

• USA: Cause of death (COD) and manner of death (MOD) are sections in all state death certificates that must be completed by the certifier (medical examiner, attending physician, or coroner). In most states there are only five acceptable options for MOD classification: natural, accident, suicide, homicide, and undetermined. MOD classification is an American invention and is not addressed in the International Classification of Diseases as promulgated by the Word Health Organization. The guideline from the National Association of Medical Examiners also explains that deaths directly due to toxic effects of a drug or poison have traditionally been classified as an accident, assuming no intent for self-harm as that would then be considered suicide. The rapidly growing burden of deaths from drug intoxication likely obscures drug intoxication suicides. And while these deaths may not have been intentional, the use of the substances and subsequent fatal drug overdoses are not entirely unforeseen or unexpected. (Source:  The Impact of the Opioid Crisis on Claims)
• Singapore, Taiwan, and Middle East: In these three countries/regions and others, suicide may be considered a sin and therefore completely taboo for surviving family members to deal with. This results in very few suicide verdicts recorded or indicated as a cause of death, and a coroner’s investigation is almost unheard of.
• Netherlands: While many countries still consider euthanasia against the law, insurance contracts cover this event while suicide in general is excluded, usually for the first three years of the policy life.

See also:  Suicide Trends and Risk Factors 

Claims evidence

The main challenge that 69ɫ��Ƭ claims professionals share in validating claims related to suicide is timely receipt of multiple and complex claims proofs.
 
The evaluation of evidence includes various sources, such as official cause of death documentation, post-mortem/autopsy reports, pathology results, inquest findings, witness statements, accident reports, and police evidence. Very rarely is this evidence made available at the same point in time, as many different avenues have to be explored to obtain evidence. Although this holistic and careful review of evidence may be entirely justified and necessary in the event of a claim occurring within the suicide exclusion period, it can become a long and drawn out process, bringing further anxiety to a family that is already experiencing extreme trauma. A so-called process of elimination may be required to determine that an accident is indeed exactly that, rather than a suicide.

Claims experts 

Given these challenges, claims for which suicide is confirmed or suspected as a cause of death and an exclusion is potentially applicable require expertise in many areas of claims adjudication. Claims professionals that handle these claims should be experienced adjudicators/analysts with a sound understanding of policy terms and conditions and specific exclusion wording, a deep knowledge of legal processes around determining cause of death, and an ability to communicate over the telephone with claimants – explaining processes, claim requirements, and, when necessary, any adverse decisions due to exclusion wording. These complex claims should be handled expertly, outside of day-to-day operational activities.

Suicide exclusion period

A review of exclusion periods globally does not indicate a set prescribed period. In group products a suicide exclusion may not appear at all, or if it is included, may apply for one year to new members only. Individual/retail products vary among one year, 13 months, two years, and up to a maximum of three years, with periods applying either from policy commencement or reinstatement date. Most of the challenges around a specific period occur when the date of death is close to the expiry of the exclusion period, but still within the defined time frame. Challenges related to the lapsation and reinstatement of policies also occur from time to time.

Conclusion

Suicide claims will remain a challenge for the insurance industry as long as suicide remains part of modern life. This requires us to reach a delicate equilibrium among many complex factors – from having a greater awareness of the scale of suicide and related causes of death to ensuring sound risk management for the overall sustainability of an insurance portfolio. Investment in many areas is required – from prevention and awareness campaigns to practices that ensure exclusion wording is appropriate and fair.

Within the insurance industry this complex scenario requires close collaboration among many different functions, including pricing, product development, legal, and claims teams. The harsh reality for families of insured lives plays out at the claim stage, and as an industry we must continue to equip ourselves to handle bereaved people with dignity and care, while ensuring that all contractual obligations are fulfilled.