A cancer patient has triumphed in a dispute against Discovery Life, when the National Financial Ombud Scheme (NFO) ruled that when it comes to Severe Illness Benefit claims, the illness itself – not the paperwork that confirms it – is the decisive event, reports IOL.
The disagreement concerned the insurer’s decision to decline the patient’s claim for the Severe Illness Benefit under the cancer category.
Discovery did not dispute the validity of the claim on its merits but instead relied on a technical defence, namely that the claim arose on 21 October 2023 when cover had lapsed due to unpaid premiums.
In response to an earlier provisional ruling by the NFO, Discovery Life said its policy terms unambiguously stipulate that a “life-changing event” occurs only upon objective medical confirmation and specifically, histological verification of a covered condition.
“The mere presence of symptoms, even if clinically suggestive, does not suffice to meet the contractual threshold for a valid claim under the Severe Illness Benefit,” it said.
But the ombud questioned the 21 October 2023 date. A breast biopsy was performed two days previously, received the next day, and reported as invasive breast carcinoma on 21 October 2023. Therefore, according to Discovery, the life-changing event occurred on that day.
The NFO disagreed. Denise Gabriels, Lead Ombud of the Life Insurance Division of the NFO, pointed out to the insurer that the policy did not support the proposition that the claim event is only deemed to occur upon confirmation of diagnosis.
“Discovery Life has yet to point to the provision in the policy which stipulates that a life-changing event is deemed to have occurred on the date medical confirmation of a covered condition has been received,” Gabriels said.
She added that in the absence of a deeming provision, the date of the life-changing event is the actual date of occurrence. If the evidence proves that the insured met the qualifying criteria for the disease covered by the policy when the policy was in force, the insurer is liable.
The fact that the proof – or medical confirmation and histological verification – was received when the policy was out of force does not exclude a valid claim which arose when the policy was in force.
“The evidence showed that the complainant had experienced symptoms in September 2023 when the premiums were paid. These symptoms, with the medical investigations, were consistent with and confirmed by the diagnosis of cancer in October 2023,” Gabriels noted.
The NFO was satisfied that the evidence proved that the complainant met the qualifying criteria for the disease when the cover was in place.
Discovery was ordered to pay the claim – and did – because the “life-changing event” was the cancer itself, not the paperwork that confirmed it.
IOL article – Cancer claim dispute: How Discovery Life's technical defence failed (Open access)
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