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CR388 Retrenchment/ interpretation/ contra proferentum

CR388 Retrenchment/ interpretation/ contra proferentum Policy excluding any retrenchment claim “where the retrenchment was announced within the first 6 months” – on the specific facts of this case, employer letter giving notice of proposed restructure and inviting consultation not an announcement of insured’s retrenchment – his actual retrenchment announced after expiry of the six month […]

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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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CR356 Interpretation Insurance policy contract

CR356 Interpretation Insurance policy contract: interpretation and application of pre-existing conditions exclusions clause. Introduction This case concerns the complainant’s eligibility for a Disability Income Benefit, payable in terms of the provisions of a group disability income benefit insurance policy issued to an employer. The issue in contention was the interpretation and application of a pre-existing […]

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CR340 Interpretation Definition of diabetes.

CR340 Interpretation Definition of diabetes. Background Mrs M had a policy that provided cover inter alia for diabetes. The diabetes benefit was set out as follows in the contract: “Diabetes Diagnosis by a paediatrician, endocrinologist or physician specialist of Type 1 diabetes. 10% of the Cover Amount is payable.” On 08.10.2009 she visited a specialist […]

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CR326 Interpretation / Exclusion

CR326 Interpretation / Exclusion Interpretation – meaning to be given to wording of an exclusion for “intervertebral disc disorders” – insurer using International Classification of Diseases (ICD) coding and descriptions Background 1. The complainant was hospitalised for a back operation and, having been off work for some months, claimed sickness benefits under his policy. His […]

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CR325 Interpretation / Policy wording

CR325 Interpretation / Policy wording Interpretation – policy requiring that certificate by a medical practitioner be furnished for a sickness benefit claim – certificate provided by policyholder issued by a psychologist, not a medical practitioner – insurer refusing to pay claim Background 1. The complainant, a senior public prosecutor, had an episode of depression/anxiety in […]

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CR324 Interpretation – ambiguity – application of the contra proferentem rule

CR324 Interpretation Interpretation – ambiguity – application of the contra proferentem rule. A Hospital Cash Back Plan provided the life insured with cover for the event of his hospitalisation. He became hospitalised for five days, and the issue that arose was the number of days for which the benefit was payable in terms of the […]

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CR310 Interpretation – Termination of cover upon a policyholder “ceasing to substantially practice his profession”

Interpretation CR310 Termination of cover upon a policyholder “ceasing to substantially practice his profession” as envisaged in policy provision. Background The complainant, a marketer by profession, had been a policyholder with the insurer since about 1995. In January 2009, shortly after emigrating to Canada, he was involved in a serious motor vehicle collision in which […]

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CR303 Interpretation – Meaning of redundancy/retrenchment

Interpretation CR303 Meaning of redundancy/retrenchment Background 1. The complainant, a salesman for a truck company, lost his job when he did not meet his sales targets. He disputed his dismissal, and the dispute was settled. The settlement agreement stated that the employer would pay a severance package to him, consisting of some R10 000 notice […]

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CR283 Interpretation Claim declined – policy covering cancer of “the genitals including cervix,

CR283 Interpretation Claim declined – policy covering cancer of “the genitals including cervix, uterus, vagina and vulva” – insurer contending that complainant’s ovarian cancer not covered. Background The policy was described as a “Cancer Protection Plan for Women” and the insurer undertook to pay the benefit for: “Positive diagnosis of cancer in the breast or […]

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