2016-09-11

Humber The Business School

Sanjiv Sawh

LEGAL FRAMEWORK GOVERNING LIFE INSURANCE

Risk the probability of harm, injury, loss,

danger or destruction, occurring in the
future.

Losses can be emotional, physical or

financial

Speculative Risk vs. Pure Risk

1. Speculative Risk- has three alternatives

I. Loss
II. No change
III. Gain

2. Pure Risk- has two alternatives

I. Loss
II. No change

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Pure Risk 4 types

1. Personal Risk

2. Property Risk

3. Liability Risk

4. Failure of others

Perils and Hazards

Losses are caused by perils

1. Peril

All pure risks exist because of perils.

2. Hazard

Insurance manages risk

Risk is measured by severity and frequency

Look at financial implications

most severe can cause financial ruin
while less severe may require financial adjustments that
result in a lower standard of living

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Risk Management Strategies

Primary Strategies

1. Risk Control
Risk reduction
Risk Avoidance

2. Risk Financing
Risk Retention
Risk Transference

Risk Management Strategies

Insurer will assume risk based on its underwriting

process

Actuaries will base their estimates of payout for

premium calculations
Will use statistics to
Law of large numbers
Law of probability
Mortality tables
Morbidity tables

Insurers will then predict returns on investments for

the premiums they will collect

Benefits that the insurer will payout is from a

combination of premiums and investment returns

Life insurance
covers the risk of one or more persons dying.

Accident & Sickness insurance

covers loss of health in several ways:

Loss, due to accident or sickness, of the ability to work at gainful employment

(disability insurance)

Onset of a diagnosed illness covered by the contract, such as cancer, heart

attack, or stroke (critical illness)

Accidental death

Accidental dismemberment

Reimbursement of medical fees and drugs

Long term care insurance

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Risks Faced By Individuals

Loss of income during the period of family obligations

Premature death eliminates a source of income
Disability reduces/eliminates income temporarily or
permanently

Loss of wealth
Medical expenses not covered by provincial plans
Inadequate coverage -government health care coverage
Travel Medical expenses while travelling abroad
Long-term care

What is insurance?
Insurance can be purchased by individuals, groups and
businesses

Insurance agents sell life insurance, disability income

insurance, health insurance (accident and sickness) and
investments

Coverage is the face amount of a life insurance contract or

the benefit received from a disability income contract or
reimbursement amount from a Health insurance contract.

Agents are required to purchase personal liability insurance

Errors and Omissions Insurance. Protects them from
claims that arise from dissatisfied clients

Agent Requirements
Be licensed
Enter into an agency contract
Practise the highest standards of ethics
Acquire errors and omissions insurance
Governed provincially by Financial Service Commission
of Ontario (FSCO)

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Be Licensed provincially licensed

Successful completion of qualification exam

Satisfactory evidence that the applicant is of good

character, reasonable educational background, good
record of previous employment

Satisfactory evidence that the applicant is acting in

good faith for purposes other than to simply sell
insurance to themselves or family members

Permitted to sell
Life insurance
Segregated funds
Annuities
Accident and sickness

Agency Contract

Between the agent and the insurer/insurers

Insurer principal in the contract

Instructions to the agent by the principal and outlines

compensation defines the relationship

Law of Agency authorizes an agent to bind the

insurance company with a third party

Authority takes 2 forms:

Actual Authority and Apparent Authority

Rights and Obligations in an Agency Relationship

Agent
follow professional standards
Agency relationship with principal(s) and clients
Insurer
Follow regulatory requirements
Honour commitments to agents and clients
Client
Must not misrepresent any information to agents and insurers

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Actual Authority and Apparent Authority

Actual Authority what the principal has instructed the agent to do
Straightforward and certain tasks
Soliciting insurance applications
Collecting the initial premium
Delivering the policy
Also defines tasks the agent is prevented to do

Apparent Authority Implies or suggests that the agent has been

authorized to do
Grey area that is not defined by specific activities
Applies to many job undertaken by the agent

Agents:

Independent agent

Managing General Agents

Captive agent

Duties of an Agent

1. Find prospects who wish to apply for insurance

2. Help each one assess which insurance products fits best

based on their needs and how much

3. Work with the applicant to correctly complete the

application form

4. Collect initial premium

5. Deliver the policy

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Insurance Policy is a contract

Elements of a contract
1. Intention

2. Offer and Acceptance

3. Consideration

4. Capacity

5. Legality

Contract
An insurance policy is a contract and subject to the
provisions of Canadian Law

Contract is a promise or set of promises that the law

will enforce

Insurance policies are simple contracts can be

enforced as long as it meets certain requirements
Offer and Acceptance (Mutual assent or bargain)

Consideration exchange of value

Parties to an insurance policy:

Based on the concept of an insurer issuing a contract of
insurance to a policy owner that promises certain benefits,
and charging a fee in the form of policy premiums to cover
the payment of those benefits.

Premiums are invested by the insurer o that the promise of

the contract will be honoured when a claim is made

Premiums are based on the probability of the insurer

having to payout.

Beneficiary is the person(s), group, organization, company

or estate to whom the proceeds of a policy are paid

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Parties to an insurance policy:

Promise varies depending to the type of contract issued.
Life insurance contracts promise to pay a sum of money
called the face value or death benefit upon the death of
the life insured
The payment is made to the beneficiary
Premiums are based on mortality tables

What is insurance?
Disability Income insurance promise to pay a monthly
sum of money called the monthly benefit when the
insured is sick or injured.
The payment is made to the insured to replace lost
income when the policy owner is unable to work
Premiums are based on morbidity tables

What is insurance?
Health insurance promise to make a payment or
reimbursement to the insurer against a variety of
medical expenses based on the contract.
Accident and sickness policy will reimburse
prescription drugs or dental expenses.
Critical illness policy will make a lump sum payment if
a life-threatening illness has been diagnosed.
Long term care insurance makes a monthly payment
to a facility that provides care.

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Contract
Void contract has no legal force
Applicant provided false information on the application
and the policy was issued it can be voided
If it is based on an unlawful act
Voidable contract if one party has been wronged by
another
Contracts with minors they cannot be bound by a
contract
Unenforceable contract a valid contract but it cannot
be enforced in courts
A need for legal capacity
A meeting of the minds
No evidence of fraud, forgery or theft

Contract
Need for Legal Capacity
A person cannot enter into, exercise rights in, or deal with
a life insurance policy is they are under the mentally
incompetent
Requires a parent or guardian for minors and legally
appointed rep on behalf of mentally incompetent
individuals
Meeting of the Minds
Mistake or misrepresentation

Contract
Meeting of the Minds
Mistake only when the mistake affects the intent of the
contract and would have affected the decisions of the
parties is considered in looking at whether to make the
contract invalid
Unilateral mistake made by one party and can be remedied
Mutual mistake when a persons intends a contract for one
thing and the other party intends it for another
Example if the applicant intended to insure the life of one
party and the insurer intended to insure the life of another
invalidate the contract
Common mistake when both parties make the same
mistake and enter into a contract not intended by either of
them
Example if both the applicant and the insurer intended to
insure the life of an already deceased party - negate or
vitiate the contract

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Contract
Meeting of the Minds
Misrepresentation meetings of the mind may not be
genuine if the insurer entered into the contract through
the misrepresentation of the other party policy owner or
life insured

Life insurance contracts induced by material

misrepresentation remain in force in full force and effect
until invalidated

Material misrepresentation can be through untrue

disclosure or non-disclosure

a misrepresentation of a fact, such that, if the truth had

been known, a reasonable insurer would have refused to
issue the insurance or would have charged a higher
premium for it

Contract
Meeting of the Minds
Material misrepresentation
Can be used as a ground to terminate the contract when it
is material to risk and known to the party making it
If discovered during the 2 year period of issue contestable
period and the insured passes away the death benefit will
not be paid.
If discovered after the period, the benefit will be paid
except in the cases of fraud

Contract
Meeting of the Minds
Material misrepresentation
Fraud is a type of misrepresentation deliberately made
with the intent of deceiving the other party *no 2 year
period of contestability
Forgery is also misrepresentation

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Contract
Meeting of the Minds
Innocent or negligent Misrepresentation made without
the intent to deceive
A mistake is not a conscious act
A misrepresentation may or may not be a conscious act

What will the insurer most likely do with a

misrepresentation or misstatement of age?

Role of the Agent During Application

if the agent knowingly records incorrect answers, the
insurer will not have accurate and/or complete
information
Agent actions constitute a fraud on the company
Agent and applicant conspire to conceal material facts
Agent does not disclose a material misrepresentation is
not revealed to the insurance company

Constructive notice insurer was given all the facts

Legal recourse against the agent or agent and applicant

Role of the Agent During Application

Assists the applicant in completing the application
1. Personal information provided by the proposed policy owner
Supports ownership including financial information

2. Medical information provided by the proposed life insured

3 levels of testing depends on underwriting requirements
Non-medical preformed by agent
Para-medical performed by nurse
Full-medical performed by doctor
Medical Information Bureau (MIB)
Inspection report for occupational or lifestyle-related info
Drug and Alcohol Questionnaire
Hazardous ports and Occupations Questionnaire

3. Product details confirming information provided by the

agent

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Role of the Agent During Application

What do the following mean?
Accept the risk
Reject the risk
Rate the risk
Rated premiums
Exclusion riders

Role of the Agent

Delivery of Policy
Policy is not if force until all delivery requirements are
met
Premiums paid
Changes in insurability acknowledged
Receipt of delivery

Recession: 10 Day Free Look

Time to review and
Can return the policy for a full refund

Role of the Agent During Application

Sources of information
Two-Party Contract Three-Party Contract
(same person as life (applicant is different
insured) from life insured)

Personal Information Provided by applicant Provided by applicant

and life inured

Medical Information Provided by applicant Provided by life inured

Details of Proposed Provided by agent; Provided by agent;

Product understood by understood by
applicant applicant

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Application For Life Insurance

The following needs to be addressed along with the
sources of information
Establish an insurable interest
Clients need is being met
Named beneficiary
Settlement option chosen
Universal life contracts a death benefit has been chosen

Application For Life Insurance

The following needs to be addressed along with the
sources of information
Contract Suits the Need
Insurance company accepts the risk (insurer)
Person who makes the contract is the insured can also be
the policy owner
Unilateral contracts insurance company is the only party
bound by the contract and I obliged to fulfil the contract
as long as premium are paid whereas the inured can
cancel it at any time
Personal contracts both insured and life insured are the
same person
Third-Party contract - insured and life insured are different
Joint-first-to-die
Joint-last-(or second) to-die
Give an example of each and when they suit need?

Application For Life Insurance

The following needs to be addressed along with the
sources of information
Name a Beneficiary
Important to select the most appropriate beneficiary and
review regularly to see if changes need to be made
4 Primary Classes
Beneficiary for value collateral assignment
Preferred beneficiary spouse, parent, child or
grandchild
Ordinary beneficiary
Estate beneficiary
Revocable
Irrevocable
The Estate

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Beneficiary is the person(s), group, organization, company or

estate to whom the proceeds of a policy are paid

Key terms:
1. Revocable versus irrevocable
2. Insurable interest
3. Contingent beneficiary

Choosing a Beneficiary and creditor protection

The relationship between the life insured and the

beneficiary that is important in determining creditor
protection
Will not be eligible if made in an attempt to defraud

Application For Life Insurance

The following needs to be addressed along with the
sources of information
Name a Beneficiary
Revocable
Policy owner may change the beneficiary named
Irrevocable
In effect, in control of the policy
Must consent for the policy owner to surrender the policy
for cash, to borrow against the cash value or to assign
Quebec the spouse is automatically irrevocable unles
otherwise stated
The Estate

Application For Life Insurance

The following needs to be addressed along with the
sources of information
Name a Beneficiary
Revocable
Policy owner may change the beneficiary named
Irrevocable
In effect, in control of the policy
Must consent for the policy owner to surrender the policy
for cash, to borrow against the cash value or to assign
Quebec the spouse is automatically irrevocable unles
otherwise stated
The Estate

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Application For Life Insurance

Naming a Person as a Beneficiary
Spouse, parent, child or grandchild always protected from
claims of the policy owners creditors
Contingent beneficiary if primary beneficiary is not living
when the insured dies
Intestate no will and the disposition of the proceeds will
be distributed according to the laws of intestacy

Application For Life Insurance

Naming a Class of Persons as Beneficiary
All members receive proceeds without any being left out
Example To all my children

Naming a Business as Beneficiary

Allow for an orderly financial transition
Place coverage on the lives of shareholders, partners,
owners or key persons

Naming a Trustee as Beneficiary

When proceeds are to managed for the benefit of another
party
Example, minors, mentally incompetent

Assignment of a Policy
Absolute Assignment
Transferring ownership
Disposition for tax purposes
New owner = policy holder and has can do anything an
owner can (can designate beneficiaries withdraw money
from the policy, surrender the policy etc.)

Collateral Assignment
With permanent policies that have a large cash value
Used as collateral
Restricts what a policy holder can do if it impacts the
security being held

Naming a Trustee as Beneficiary

When proceeds are to managed for the benefit of another
party
Example, minors, mentally incompetent

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Naming the estate as Beneficiary

Policy owner directs the disposition in their will
If a beneficiary is named I the will and a later declaration
names a different beneficiary the one named closest to
death will prevail
Can be used to provide liquidity estate costs, taxes, to
start a trust
Increases probate fees
Does not provide creditor protection

Application For Life Insurance

Choose a Settlement Option
Settlement option may be chosen by the policy owner or
beneficiary

Lump-Sum Payment

Interest Option
Maybe suitable for a beneficiary that has other income sources
Proceed are invested and pays the interest
On the death of the beneficiary the sum is paid out to the
remainder beneficiaries

Instalment Option fixed-amount option

Pay out proceeds plus interest over a specified period until
exhausted

Life Annuity Option

Invested as a single-lump-sum premium to purchase a life annuity
Provides permanent income for the beneficiary

Application For Life Insurance additional terms

The following constitute the entire agreement
Application
Policy
Relevant documents attached to the policy upon issue
Any amendments to the policy in writing after issue

Exclusions
Death caused by that which is defined in the excluded causes would not result in any benefits
being paid.
Pre-existing conditions

Suicide Clause
First two(2) to three (3) years of the policy or reinstatement

Living Benefits
Some policies allow for an advancement of death benefits if diagnosed with terminal illness

Cash Surrender Value

Permanent policies will have an accumulation of cash values
Payable to the policy holder if cancelled
Able to take a policy loan or collateral loan (know the distinction)

Riders
Additional coverage along with the policy
Additional or attached benefits
Examples..

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Application For Group Insurance

Policy is issued to the policy owner, often an employer, as a
master contract
Group insured (group plan member) each person insured
under the master contract
Certificate of Insurance (benefit Booklet) what members
receive instead of the actual policy
Pools the risk of individual members of the group
Standard group requires at least 25 people
Smaller group are still insurable need to show evidence of
insurability
Risk of adverse selection is lessened by
Members must be full-time
75% of eligible employees must be enrolled
Non-medical evidence limit (NME)

Application For Group Insurance

Establishing Eligibility
Actively-at-Work-Provision
Found in all employer/employee group insurance contracts
Good Health assumptions are used about the health of each
employee prior to their group membership

Probationary Period
Length of time that a new group member must wait to join the
group plan - 1-6 months

Eligibility Period
Period of time within which the employee must apply for group
coverage after probationary period usually 31 days

Waiting Period two meanings

1. Period of time the employee must wait before joining the
group typically 3 months
2. Period after the onset of disability before benefit is paid 7
days to 6 months

Disability and Health Insurance Premium

Determined by the applicants
Age
must be of working age (18-60) - incident increases

Gender
Women suffer from more disabilities than men and for longer period

Smoking status
Higher morbidity rates

Occupational Classification
5 categories based on claim being made due to hazard of the occupation
and likely duration

Motivation
More educated or better trained have higher levels of motivation to return

Stability
Occupation and residency

Claims History

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Group Insurance Premium

1. Pay for the benefits of the policy
2. Cover the administrative expenses of the insurer
3. Be fair to the policy owner based on other similar groups

Determined by:
Experience rating

Manual rating

Blended rating

Tax Deductibility of Group Insurance Premium

If the employee pays the premium (after-tax dollars) the
benefits received are tax free
If the employer pays the premium the premiums are a taxable
benefit
If declared benefits are tax free
If not declared the benefits are taxable

Application For Annuities

Annuities
Agreement to pay a fixed amount over a specified period of
time
Individual or group
Policy holder
Determines who receives the payment
May designate a beneficiary for remaining payments if any

Annuitant (life insured)

The life on which the annuity is based
In most cases they receive the payment

Payee
Receive the annuity payments

Immediate versus deferred

Immediate has first payment on the next period monthly,
quarterly semi-annually or annually
Deferred annuities has a accumulation period and payout period

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Application For Segregated Funds

Segregated Funds
Individual Variable Insurance Contract (IVIC)
Premiums invested in a segregated funds managed by the
insurance company
Payout at least 75% of premium on death or maturity
Parties are the same as an annuity

Application For Individual and Group Accident and Sickness

Insurance
Accidental death and dismemberment
Covers physical loss or death due to an accident
Payout on dismemberment is based on a percentage of death
benefit and loss

Disability
Full or partial
Permanent or temporary

Drug Insurance
Private coverage outside of group coverage

Critical Illness
Lump sum payable on diagnosis of covered illnesses and waiting
period of at least 30 days

Long-Term care
Activities of daily living
Toileting, transferring, eating, bladder control, dressing

Application For Disability and health Insurance

Process for applying is similar to life insurance with a few
exceptions
AD or AD&D no need to name a beneficiary
No selection for settlement options
TIA is issued and it begins coverage for accident only and not
disabilities caused by illness
Illness coverage begins after the policy is issued most will
not cover illnesses that commences within 90-days
Pre-existing conditions
Disability income policy is always a two-party policy
Personal accident and sickness insurance is always a two-
party policy except when a family plan provides for coverage
for spouses and children third-party

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Application For Disability and health Insurance

Choose a Deductible and Co-Insurance
Risk management technique
Reduce premiums and reduce reimbursement received
Decided upon in the application

Deductible
Single or family
Insured receives the benefit of the single deductible
Family deductible is the maximum amount that will be
deducted for all claims over the year

Co-Insurance
When the group insured must pay a fixed percentage o
costs
E.g. a 80% co-insurance factor will reduce the claim by 20%

All Completed Application

The agent now fulfils those duties that are essential to forming
the contract
1. Witnessing the signature of the applicant
2. Obtaining the first premium
3. Forwarding the application to the insurer for underwriting

All Completed Application

Witnessing the signature of the applicant

Obtaining the first premium

Based on standard rates and subject to certain limits
Not collected for applicants above age 65 or if yes to any
questions in the TIA section
TIA will contain max amount of coverage and provide a
guaranteed amount of coverage during the underwriting
process

Forwarding the application to the insurer for underwriting

If the policy is rated, an amendment will be issued for the policy
owner to acknowledge and accept

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How Premiums are Calculated

Life insurance companies have two sources of income

Premiums and investment earning from their portfolio
Income is used to pay all benefits that are due to policyholders
and pay operating expenses

How underwriting relates to premiums

Rates of mortality Mortality Tables Premium rates

How Premiums Are Calculated

Life insurance companies have two sources of income

Premiums and investment earning from their portfolio
Income is used to pay all benefits that are due to policyholders
and pay operating expenses

Gross Premium = Mortality rates + Investment Income + Expense Load

Example of expenses
Cost of selling the policy (e.g., marketing, salaries or commissions to agents);
Underwriting the policy (e.g., processing applications, paying for medical exams);
Issuing and administering the policy;
Paying income taxes;
Investigating claims;
Paying death benefits and the profits sought by shareholders.

Disability and Health Insurance Premium

How underwriting relates to premiums

Morbidity Tables Premium rates

Morbidity Rates

Separate morbidity tables are used for different groups of

people, once they represent different levels of risk for the
insurer

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Claims differ
An life insurance policy
A disability policy
An accident and sickness policy

In addition to private benefits there are government

benefits
How are claim payments made i.e. lump sum, monthly,
weekly
Tax implications

Claims for Life Insurance Benefits

Submit to a claims examiner
Policy number
Name and address of the deceased
Beneficiarys name
Claimant statement
Attending Physician Statement (APS) date and cause of
death
If required copy of death certificate, coroners report or
provincial medical examiners report
If estate is beneficiary certified copy of the letters of
probate or letters of administration
Policy of loss-of-policy form must be submitted to the
insurer

Claims for Life Insurance Benefits

Claim examiner reviews documentation and claims
statement to confirm
Insurance contract was in force at the time of the claim
If the deceased was the life insured
Loss is covered by the contract
Claimant is the same as that named in the policy

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Taxation of a Life Policy

Death Benefit
Received by the beneficiary tax-free
When received by the estate it forms part of the estate
and probate fees are factored

Disability Income Claims

Monthly benefit
Insurer must be satisfied that the disability claim is for
a disability covered in the policy
Four common types of fraud occur within the context
of disability claims
Misrepresentation of disability
Unreported income
Unreported return to work
Misrepresentation of medical treatment
Claimant's statement
Date on which disability began
Cause, nature and treatment of the disability
Identity of claimants physician

Disability Income Claims

Coordination of disability benefits
Workers compensation
CPP
Group disability plans
Individual plans
Income from another occupation

All sources maximum

Limits disability benefits received from all sources
Your total monthly income while cannot exceed 65% of your
gross monthly earning as of the date your disability
commenced. If your total income exceeds 65%, your disability
benefit will be reduced accordingly.

Offset Clause
Reduces any amounts received from specified sources from
the benefit payable by the policy
Amount payable by deducting from the benefit

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Disability Income Claims

Presumptive Disability benefit
Loss of limbs, sight, hearing or speech
Full benefits are paid for the entire period or for life,
whether or not the person can return to work

Recurring Disability benefit

Recurs for the same or related cause as an earlier claim
within a specified period of time usually 6 months after
returning to full time employment
Treated as continuation no elimination period
Benefit period continues and does not restart

Accident and Sickness Policy Benefits

Coordination of Benefits
Coordinate health and dental claims from all group
plans under which a person is covered
Makes certain that an insured who has insurance
through a spouses group plan or through parent
group plans will not profit through multiple claims for
the expenses

Denying Claims
Policy has lapsed
Policy surrendered by policy owner for csv
Policy has expired by its own terms
Material misrepresentation by the applicant or life
insured within the first years of the policy
Fraud
Claim does not satisfy the definitions of disability in
the policy
Suicide has occurred within 2 years of policy issue,
replacement or reinstatement
Claim arises from an exclusion

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Ethical Conduct
Measure of a life insurance agents business character
and their adherence to the code of ethics established
by the CLHIA and Advocis.
Based on:
Knowing your client
Fiduciary responsibility
Privacy and confidentiality
Professional Standards

Keep records and notes of all interactions with clients.

Knowing the Client

Know your client and assess suitability
Understand the initial need that brought the client to
consider life insurance 3 predictable risks
Monitor the clients needs
Document the relationship
KYC/NCAF
Matching right product to the risk facing the client and
ensure adequate coverage and recommend
Provide the correct information according to your
knowledge and expertise

Fiduciary Responsibility
Fiduciary is someone who has a responsibility of
confidentiality and trust for another
Special relationship based on trust and confidentiality

Fiduciary duty the responsibility of confidentiality and

trust

Fiduciary relationship the relationship between a

fiduciary and his/her client

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Privacy and Confidentiality

Ethical and legally required for the agent to protect
and use personal information collected properly
Personal Information Protection and Electronic
Document Act (PIPEDA) - federal
If written consent of the client has not been given to
release information to other people or organizations, such
information will only be used for the purpose for which it
was supplied
Two types of personal information you will collect
Financial
Health information (including family history)

Privacy and Confidentiality

Canadian Life and Health Insurance Association
(CLHIA) state that personal information should be
provided to others only:
If the individual gives his or her consent
If disclosure is required by law
If the information is reasonably necessary to determine
eligibility
To protect the insurer against fraud or misrepresentation
If the information is disclosed in the discharge of a public
duty

Activities which can be judged guilty of misconduct

Holding Out
Tied-selling
Misrepresentation
Commission Splitting
Inappropriate Replacement Churning and Twisting
Trafficking in Insurance
Inducing to insure
Fronting
Unnecessary delay in delivering policies
Misappropriating client funds (commingling of funds)
Forgery
Misusing illustrations
Defamation
Conflicts of interest
Unfair trade practices

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