Everybody knows somebody whose claim was refused. It is the story that circulates, and it is the reason a great many applications are never completed. So it is worth being precise about why claims actually fail, because the reasons are surprisingly consistent — and almost all of them are addressable at the point of application rather than at the point of claim.
What actually causes declined claims
1. Non-disclosure — by a wide margin the biggest cause
The application asks about your medical history, family history, occupation, habits and pastimes. Answer any of it incompletely and you have given the insurer a basis to avoid the policy when a claim arrives, even where the omission is unrelated to the cause of the claim.
People do this for understandable reasons: they forget an investigation from years ago, they think a resolved condition is irrelevant, or they are afraid of a loading. The result is the same. An insurer that knew about a condition and accepted it has bought that risk. An insurer that finds out at claim stage has not.
The fix: disclose everything, including things you think are trivial. If you are unsure whether something counts, disclose it and let the underwriter decide. Keep a copy of the completed application.
2. Falling outside a policy definition
Especially in critical illness. "Cancer", "heart attack" and "stroke" are defined terms with clinical thresholds, and a real diagnosis can sit outside the definition. Health policies decline claims for treatment outside network, or without pre-authorisation, or above a limit.
The fix: read the definitions schedule before buying. Ask what a partial or early-stage diagnosis pays. Understand the survival period.
3. The policy had lapsed
An unpaid premium during a difficult month, a changed bank account, a card that expired. Cover ends and nobody notices until it matters.
The fix: standing order rather than manual payment, and open every letter your insurer sends. If money is tight, call before you miss a payment — there are almost always options while a policy is in force, and almost none once it has lapsed.
4. Late notification or missing documentation
Policies impose notification periods. Miss them and even a valid claim can be prejudiced.
The fix: notify immediately, in writing, even before you have all the documents.
5. A specific exclusion applied
Pre-existing conditions, hazardous pastimes, suicide within an early policy period, business use on a private motor policy.
The fix: read the exclusions when you buy. They are shorter than the rest of the policy and far more informative.
Notice what is missing from this list: "the company simply refused because it felt like it". That is not how regulated insurers behave, because it is not a sustainable way to run a business that depends on people believing it will pay.
Have a quotation, illustration or policy in front of you? Send it over and I will read it with you line by line before you commit — no charge, and no obligation to buy anything.
Get it reviewedThe claims process, step by step
- Notify the insurer immediately — by phone, then in writing. Note the date, the person and any reference number.
- Obtain the claim form for the specific benefit. Life, critical illness, health and motor all use different forms.
- Gather the documents. For a death claim: death certificate, policy document, identification for the beneficiary, and often a physician's statement. For critical illness: the specialist's report, diagnostic evidence and test results. For health: itemised invoices and, where required, pre-authorisation.
- Submit everything at once. Partial submissions cause most of the delay people attribute to reluctance.
- Keep copies of everything and a log of every call.
- Follow up on a schedule — weekly, politely, in writing, to the same named person.
Straightforward death claims with complete documentation are usually settled in weeks rather than months. Claims within the first two years of a policy attract closer scrutiny, because that is the period in which non-disclosure is investigated.
How to judge an insurer before you buy
You cannot know how a company will behave on your claim. You can assess the things that correlate with it.
- Registration and supervision. Insurers in Trinidad and Tobago are registered and supervised by the Central Bank of Trinidad and Tobago under the Insurance Act, 2018 (Act No. 4 of 2018, as amended in 2020), which strengthened the framework for policyholder protection, capital adequacy and market conduct. The Central Bank has also issued a Market Conduct Guideline for registrants. Confirm any insurer you are considering is registered.
- Financial strength. Where the insurer or its parent is publicly listed, financial statements and annual reports are public. Read them, or ask your accountant to.
- Longevity and scale in this market. A company that has paid claims here for decades has a reputation it cannot afford to damage.
- Claims experience of people you know. Ask around. Local reputation is imperfect but not worthless.
- How they behave when selling. An adviser who volunteers the exclusions, hands you the definitions schedule and encourages you to take the illustration home is showing you how the relationship will run.
If a claim is declined
A decline is not the end of the process.
- Get the reason in writing, with reference to the specific policy clause relied on.
- Check it against your policy — and against the application you completed. Errors happen.
- Use the insurer's internal dispute resolution process. A significant proportion of declines are overturned at this stage, often because additional medical evidence resolves a definitional question.
- Escalate to the Office of the Financial Services Ombudsman. The OFSO handles complaints about banks and insurance companies from individuals and small businesses, and the service is free. You must first take the complaint through the institution's own dispute resolution process; you may then bring it to the OFSO within 180 days of receiving the institution's decision. The office is at the Central Bank Building, Independence Square, Port of Spain, with an office in Scarborough, Tobago.
- Legal advice, if the sum justifies it and the Ombudsman route is exhausted.
The three habits that make a claim straightforward
- Disclose completely at application, and keep a copy of what you disclosed.
- Tell someone the policy exists. A policy nobody knows about is never claimed. Keep a one-page list of insurers, policy numbers and contacts with your important papers.
- Keep it in force. Standing order, current bank details, and a call to your adviser before you miss a payment rather than after.
The honest summary
Insurers pay the overwhelming majority of claims, because they must. The claims that fail overwhelmingly fail for reasons created at the application stage, not at the claim stage — and those reasons are within your control on the day you apply.
Which means the most important half-hour in the life of your policy is the one in which you fill in the form honestly.
Why I place business with Guardian
Guardian Life of The Caribbean Limited is a subsidiary of Guardian Holdings Limited, which is publicly listed on the Trinidad and Tobago Stock Exchange — meaning its financial statements, annual reports and share price are public and you can examine them yourself rather than taking anyone's word for it. It underwrites all classes of long-term individual and group life, health and pensions business, and is registered and supervised by the Central Bank of Trinidad and Tobago under the Insurance Act, 2018. Guardian General Insurance Limited handles the general side.
Guardian's easiClaim facility handles health claim submission, and claims can be started online.
None of that guarantees any individual claim — nothing does, and the things in this article that actually determine outcomes are disclosure, documentation and prompt notification. But scale, listed-company transparency and Central Bank supervision are the checks available to you, and Guardian stands up to all three.
Noble Accounting & Insurance is an appointed adviser for Guardian Group (Guardian Life of The Caribbean Limited and Guardian General Insurance Limited). Where an article recommends an insurance or annuity solution, that recommendation will be a Guardian Group product, and we are remunerated by Guardian Group when business is placed. Product features described here are drawn from Guardian Group's published material; full terms, benefits, exclusions and premiums are set out in the policy documents and your personal illustration.
General information only. This article sets out general information about accounting, taxation and insurance matters in Trinidad and Tobago as understood at the date of publication. Rates, thresholds, product features, forms and filing procedures change, and the right course depends on your particular circumstances. It is not accounting, tax, legal or financial advice and should not be relied on as a substitute for professional consultation. Please confirm current requirements with the Inland Revenue Division, the National Insurance Board, the Central Bank of Trinidad and Tobago or your insurer as applicable — or speak with us before acting.