CR361 Dread disease /Exclusion Clause
Dread disease /Exclusion Clause
Claim for dread disease benefit on grounds of cancer – claim not meeting policy criteria – claim settled
1. The policyholder initially consulted her general practitioner who referred her to a Specialist Physician as she was suffering from a chest infection. She was later hospitalised and treated for pneumonia. Thereafter on 30/04/2014 she was re-admitted with a swollen leg and found to have a large pleural effusion. On 12/05/2014 she was diagnosed with Stage 4 pancreatic cancer and subsequently passed away on 16/05/2014.
2. The complainant’s claim for a dread disease benefit was declined by the insurer on the ground that the deceased did not survive the 28 day waiting period after diagnosis.
3. The relevant clauses are as follows:
“Cancer shall mean a malignant tumour positively diagnosed with histological confirmation and characterised by the uncontrollable growth of malignant cells and invasion of tissue. The term malignant tumour includes leukaemia, lymphoma and sarcoma.”
“Survival period shall mean the twenty-eight day period commencing at Date of Occurrence.”
Payment of Benefits
“Upon the admission of a dread disease claim before the earlier of the Termination Age and the first day of the month following a Member’s sixty-fifth birthday, the insurer shall pay the Dread Disease Benefit to the Policyholder or as the Policyholder may direct, provided the Member is alive at the expiry of the Survival Period.’’
Date of Occurrence
“Shall mean the date upon which the dread disease event first manifested itself, as determined by the insurer on the basis of objective evidence obtained in Southern Africa.”
Dread Disease Event
‘’Shall mean the onset or diagnosis of any one or more of the events listed in clause 4.’’
4. The dread disease benefit is payable if the life assured survives the 28 day waiting period after diagnosis or onset as per the policy terms. The full sum assured for the dread disease benefit is R162 000.00. The life assured did not meet the requirement of surviving for at least 28 days after diagnosis.
5. The complainant submitted that the life assured survived 28 days after the onset of the condition. The life assured’s general practitioner confirmed that it is likely that the cancer was present even though it was not detected and that the other illnesses that she was suffering from could have emanated from the cancer. The specialist physician further confirmed that the medication that the life assured used, would have improved the cancer infiltration.
6. We forwarded the complainant’s arguments to the insurer regarding the survival period and they did not change their stance. We then asked an independent medical specialist for an opinion and he outlined that the deceased was suffering from cancer prior to the existence of the policy. The independent medical specialist confirmed that the results of the life assured’s CT scan “showed pancreatic abnormalities considered to be the site of the primary malignancy”. He noted that there was no evidence to indicate that the life assured or her doctors were aware of the malignant cells until they received the results of the CT scan . He further confirmed that the life assured’s clinical presentation were manifestations of an initially ‘’hidden’’pancreatic cancer.
7. The insurer considered the report from the independent medical specialist and admitted the claim.