CR320 Causation. See also exceptions, exclusions and waiting periods.

CR320

Causation. See also exceptions, exclusions and waiting periods.

Exclusion clause – lumbosacral spinal exclusion imposed – not stated to apply where condition results indirectly from it – claim not therefore excluded.

The complainant was covered under two policies for illness and disability. She subsequently injured her thoracic spine after a fall at work and submitted a disability claim under both policies. On the medical evidence the insurer denied the claim, however, relying in each case on an exclusion clause.

In the one policy the exclusion clause read:

“In the event of a claim arising as a direct or indirect result of Disorders of the Lumbosacral Spine and Associated Structures no benefit will be payable …”

On the medical evidence the complainant’s disability was at least indirectly the result of a previously existing disorder of her spine, so that it was clear that the exclusion clause applied.

In the other policy, however, the clause read:

“The Company shall not be liable to pay any benefit in respect of any illness or disability due to a disorder of the lumbar region, its disc, nerve roots or supporting musculature…”

In the case of the second policy we suggested to the insurer that in the absence of the phrase ‘direct or indirect’, or wording akin thereto, the ambit of the exclusion was restricted to disability directly due to an injury to the lumbar region, its discs or nerve roots or muscles. We added that since the complainant’s disability was directly, and not indirectly, due to an injury to her thoracic spine and not the lumbar region, we were of the view that the claim did not fall within the ambit of the exclusion as formulated.

The insurer agreed and paid the claim under the second policy.

LS
January 2012