CR261 Exclusion clause – “any back condition” excluded

CR261

Exclusion clause – “any back condition” excluded – complainant sustaining a neck injury – neck injury not excluded.

BACKGROUND

The complainant took out a life policy that also provided for an instalment protection benefit in respect of his mortgage bond. The commencement date of the policy was 1 September 2005, and for the instalment protection benefit it covered him if he should be prevented through bodily injury, for a period in excess of 90 days, from carrying out his own occupation, and after the benefit is paid for 24 months for the event that he is also unable to carry out any other applicable occupation.

The complainant had since November 2004 been employed as a workshop manager, and when lifting a cylinder head on 15 September 2005 he sustained a neck injury, spondylosis, which could not be operated on due to his heart condition. In the result the injury rendered him permanently unfit to work either in his own occupation or at all, and he made a claim against the insurer for the instalment protection benefit.

DISCUSSION

In repudiating the claim the insurer relied on a clause that excluded liability for any injury resulting directly or indirectly from “any back condition”.

The office pointed out that the expression “any back condition” was not defined in the policy, and that the expression would therefore have to bear its ordinary meaning. We added:

“According to the Concise Oxford Dictionary, “back” means “the rear surface of the human body from the shoulders to the hips”, whereas “neck” means “the part of a person’s or animal’s body connecting the head to the rest of the body”. In terms of ordinary language the neck does not form part of the back and therefore it appears that the back exclusion would not apply.”

CONCLUSION

In response the insurer accepted that the exclusion clause did not apply. It proceeded to assess the complainant’s injury and duly paid the benefit concerned.

FOOTNOTE

The complainant was not as fortunate, however, on another claim that he made at the same time. He had taken out a similar policy with the same insurer, its inception date having been 1 November 2005, which was some six weeks after he had sustained the injury concerned. The insurer’s repudiation of that claim was upheld on the ground that the policy conditions contained a clause excluding pre-existing conditions.

The saga continued. After his injury he took out two further policies with another insurer; the one was a credit card policy with an inception date in June 2006, and the other a loan policy taken out in January 2007. That insurer’s repudiation of the claims on both policies was upheld by the office, again on an exclusion clause in each which excused the insurer from liability in the case of claims arising from medical conditions of which the complainant had been aware and which had their origin prior to the commencement of the policies.

SM
January 2009

Download Attachments

Subscribe to our Newsletter