Fedgroup Life has accepted and implemented a final determination by the Long-Term Insurance Ombud to pay a disability and critical illness claim lodged by an employee benefits consultant after initially repudiating both the woman’s claim and the ombud’s provisional determination.
Long-Term Insurance Ombud Judge Margie Victor, in a recent final determination, ruled that Fedgroup Life had failed to take a holistic approach to her claim and to have regard to the totality of the evidence.
In a similar case recently, Discovery Life was ordered by the Gauteng High Court earlier this year to pay a former stockbroker more than R25m after previously repudiating his claim that he was “totally and permanently unable” to work as a stockbroker.
Moneyweb reports that an application by Discovery Life for leave to appeal this judgment was dismissed with costs, but it has petitioned the SCA for leave to appeal the judgment and order.
In the Fedgroup Life case, the complainant – who suffered from migraines with anxiety, depression, memory loss and cognitive challenges – was insured as an employee member under a group risk policy between Fedgroup Life and her employer.
After some serious mistakes at work, and after a meeting between her and her employers, it was agreed her employment would be terminated on 18 July 2022, although she was kept on the payroll and paid premiums in respect of her risk benefits up to November 2022.
Fedgroup Life declined the income disability claim on the grounds the medical evidence “does not tender sufficient, objective medical information to support a disability as at the last day actively at work” on 18 July 2022.
The ombud said it appeared to be Fedgroup Life’s position that the termination of employment, loss of income and subsequent cancer diagnosis precipitated the complainant’s distress and disability, but this was not present before she lost her job, or “as at” 18 July 2022.
The meeting did not accept Fedgroup Life’s “overly technical argument” to justify it requiring the claimant to pay for independent reports for a review of its decision.
The final determination was that the critical illness claim must be assessed, and paid if valid, and the monthly income disability claim must be paid from the expiry of the waiting period after 18 July 2022, and must continue to be paid until there were grounds for termination of payments in terms of a clause in the policy.
Moneyweb article – Another disability claim dispute decided in favour of complainant (Open access)
See more from MedicalBrief archives:
Discovery now takes fight against R25m payout to SCA
Court dismisses Discovery’s application to appeal R25m ‘disability’ ruling
MS sufferer looks to CCMA to reverse Woolies suspension over 'incapacity'