CR219 Disability claim – claimant possessed by ancestral spirit

CR219

Disability claim – claimant possessed by ancestral spirit – not following his own occupation – graduated as a sangoma – insurer of the view that the claimant (i) has not undergone optimal treatment and (ii) is not totally and permanently disabled as defined

Background

Mr Y was a member of a group policy underwritten by the insurer. The policy provided cover, in the event of death or disability, for the outstanding balance of Mr Y’s bond account.

During December 2004, Mr Y submitted a disability claim to the insurer. His last active day at work was 31 July 2004.

The insurer rejected the claim, as it was of the view that (i) Mr Y had not undergone optimal treatment and (ii) he was not totally and permanently disabled as defined in the master policy.

The complaint was submitted to our office during May 2006.

Assessment

Mr Y had a Bachelor of Arts in Communication from UNISA and was the director of a communications company. His job entailed sourcing work from companies who wanted to advertise their products on the radio or via other media. From a newspaper article submitted by Mr Y’s attorney, Mr Y was a manager of a radio station, which he in fact launched before he was afflicted.

According to the claim documentation, Mr Y was first treated by a sangoma/traditional healer on 18 February 1993. He was diagnosed as being “possessed by his ancestral spirits who wanted to be cleansed and treated via traditional means”. By 13 June 1993 he had recovered completely.

However, during July 2004 he was again taken unconscious to the sangoma/traditional healer. He was once again diagnosed as being possessed by a violent ancestral spirit. The symptoms experienced were: severe ancestral spirit attacks about thrice a day; hearing voices demanding that he must go to sea; blackouts; severe pains throughout the body; tiredness; blurred vision and loss of appetite. The sangoma / traditional healer indicated that “this results in a sequence of amongst other things severe heart, strokes and asthmatic attacks” that “can at anytime cause cardiac failure”.

A report from a clinical psychologist was also submitted. Both the sangoma/traditional healer and the clinical psychologist concurred that western medicine would not assist Mr Y; they suggested that he be treated by traditional means and both confirmed that his prognosis was not good unless he heeded to his ancestral calling. The clinical psychologist, however, confirmed that Mr Y was not cognitively impaired and there was no evidence of an underlying psychiatric illness.

The definition of disability for the lump sum total and permanent disability benefit featuring in the master policy read as follows:

“… For the purposes hereof total and permanent disability shall mean such medically certified incapacity which prevents the Life Insured from following his own occupation or any other occupation for which he is or could reasonably be expected to become qualified by virtue of his knowledge, training, education, ability or experience …” (own emphasis).

In order to prove an enforceable claim under this benefit, Mr Y was required to prove that he was suffering from “medically certified incapacity”. On the information and documentation submitted, this office was not persuaded that Mr Y proved that he suffered a “medically certified incapacity”; Mr Y had not been medically certified as suffering from incapacity; the clinical psychologist confirmed that he did not suffer from a mental illness.

Moreover, the office could not, on the available evidence, come to the conclusion that Mr Y was permanently disabled. By both Mr Y and his medical practitioners’ admission, his condition was not necessarily permanent.

We expressed sympathy with Mr Y’s for his predicament in not being able to generate an income but we pointed out that the policy provided for a total and permanent disability benefit; it did not provide a temporary disability benefit.

Conclusion

Based on the information submitted, this office’s provisional view was that Mr Y had not established, the onus being on him, that (i) he had “medically certified incapacity” and (ii) that his condition was of a permanent nature.

Mr Y responded to the provisional ruling by submitting a report from his treating sangoma/traditional healer advising that western medicine could not be of assistance as the illness could not be medically diagnosed. He expressed his view that Mr Y’s illness was of a permanent nature and that he would never be gainfully employed again.

The office replied to Mr Y’s attorney that the policy had a special requirement that the alleged incapacity should be “medically certified” and that it was for a claimant to adduce such proof. Such proof was lacking. This office could not ignore the terms and conditions of the contract however sympathetic it may have felt towards Mr Y’s cause. Our provisional ruling was thus made final.

AR
MAY 2007

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