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CR379 Interest on late payment

Interest on late payment CR379 Dispute about calculation of payment in respect of a disability claim based on psychiatric grounds; whether interest payable. Background 1. The complainant last worked on 21 January 2014. She lodged a disability claim in respect of depression (for a lump sum) with the insurer on 10 March 2014. At this […]

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CR377 Interpretation and application of the restriction period

CR377 Interpretation and application of the restriction period due to a breach of the 20% rule in terms of section 54 of the Long-Term Insurance Act, 52 of 1998 Insurer applying restriction period at the end of the premium paying period (policy year) Background 1. The policy was an investment policy that commenced on 1 […]

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CR376 Probabilities of Accidental Death for payment of Accidental Death Benefit

CR376 Probabilities of Accidental Death for payment of Accidental Death Benefit Accidental Death Benefit – insurer accepting death as accidental on probabilities – requiring actual proof that accidental to pay benefit Background 1. The policy was a funeral policy which provided a funeral benefit of R5000 with an additional R5000 if the death was accidental. […]

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CR375 Constitution / discrimination / equality Allegation of marital status discrimination

Constitution / discrimination / equality CR375 Allegation of marital status discrimination Background – the facts and argument 1. The complainant and his wife were members of a health plan (a medical scheme) associated with the insurer, and they each also had a life policy with the insurer. 2. For such persons the insurer offered a […]

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CR374 Disability

CR374 Disability Insurer ignoring relevant considerations concerning job description and physical nature of occupation; selectively relying on certain medical evidence while ignoring contradicting medical evidence Background 1. The complainant, a farm manager, injured his right leg, knee and ankle in a tractor accident in 2012 (the tractor drove over his leg). After surgery and rehabilitation […]

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CR373 Late submission / Equity

CR373 Late submission / Equity Claim submitted late as complainant forgot she had covered the deceased; equity considered; decision in favour of the insurer Background 1. The complainant forgot that she had covered her aunt on her employer’s group funeral scheme policy. She was reminded when a consultant visited her office with a printout of […]

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CR372 Underwriting Life register entry – was it justified?

CR372 Underwriting Life register entry – was it justified? Complainants sometimes complain about an insurer’s underwriting process and protocols. In this matter a complainant who coincidently had been successful in a claim which had been the subject matter of a previous complaint, complained after her insurer refused her application for an increase in benefits. The […]

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CR371 Accident Claim for accidental benefit due to bodily injury

CR371 Accident Claim for accidental benefit due to bodily injury Background: 1. The complainant had a laminectomy and fusion of vertebrae. The operation was deemed successful but in time she suffered chronic back pain and was declared permanently disabled for her own occupation by her employer. Some time after she had been boarded, she experienced […]

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CR370 Accidental Death Policy covered “accidental death”

CR370 Accidental Death Policy covered “accidental death”; was the deceased’s death accidental? The policy covered ‘accidental death’ which was defined in the policy as a “traumatic death caused solely by external, violent, unforeseeable and visible means, occurring independent of any other causes and within 14 days of such trauma proved to the satisfaction of the […]

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CR369 Impairment Benefit Physical impairment benefit

CR369 Impairment Benefit Physical impairment benefit; claim for permanent loss of use of ankle admitted but claim for permanent loss of use of leg declined; combination of loss of use of limbs Background: 1. The complainant developed peripheral neuropathy, a condition that damages the nerves, in his right foot. The condition is said to be […]

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