CR132 Disability – further medical examinations – onus.

CR132
Disability – further medical examinations – onus.

Background

The complainant received disability benefits from the insurer as per disability policy. He suffered from multiple sclerosis which caused him to be dismissed from work. According to his previous employer his capacity to concentrate was diminishing, he needed too many breaks to refocus as he tired very quickly; he could no longer perform his daily routines and he was unable to walk, control his bladder and bowel.

He complained to this office that the insurer required him to furnish a disability certificate every three months. This he found onerous and costly. He had paid R550-00 to obtain the last certificate.

This office invited the insurer to comment on the reasonableness and necessity of this requirement in the light of the complainant’s severe illness. Instead this office received prevaricating responses from the insurer.

Discussion

This office formed the view that once the disability claim has been admitted, the probabilities are that the disability continues. The onus of establishing that an insured falls within the definition of the disability rests on the insured; thereafter the onus of rebuttal shifts to the insurer to prove that the insured is again able to engage in some other suited occupation or to perform one or more but not all the duties of his occupation. Such a determination would require a medical examination which should be for the account of the insurer.

In casu, the insurance contract provided that the insured shall as often as reasonably required by the insurer submit to medical examination at the insurer’s expense.

Consequently a provisional ruling was made that any future medical information required from the complainant be for the account of the insurer. Furthermore, that the complainant not be required to provide such information more frequently than once a year, unless his circumstances significantly altered and there were specific reasons why medical information was required after a shorter interval.

Result

Since the insurer did not make any further input when invited to do so, the provisional ruling became final.
SM/TS
April 2006

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