Handle a claim that doesn't qualify
Not every notification turns into a paid claim. Sometimes the event isn't covered, or it falls inside a stand-down period. This walkthrough covers the ineligible path.
Lodge the claim
Lodge a claim where the event date is within the rider's stand-down period.
Spot the default outcome
When you open the claim, you'll see the benefit's outcome is already set to Ineligible, with the rider's stand-down period as the reason. The system applied this default at lodgement based on configuration that reflects the cover wordings.
Note. You can't change an Ineligible outcome to Accepted. If you want to pay the claim anyway, set the outcome to Ex Gratia instead.
Send to review and communicate
Add an assessment, record a clear reason for the decision, and send for review. When the reviewer approves the assessment, the system creates a follow-up task on your queue called 'Communicate ineligible decision', with a two working day due date.
You’ll need to compile and send the decision letter to the claimant outside Simfuni, but you may upload the letter to the case in the Documents tab. Then close the task. The claim outcome is Ineligible and the case can be closed.