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CR390 Pre-existing condition exclusion / causation
CR390 Pre-existing condition exclusion / causation Exclusion clause – whether claim directly or indirectly attributable to pre-existing condition – test for legal causation The exclusion clause in the policy read: In the case of disability and severe illness benefits, [the insurer] will not pay a claim during the first twelve months of the life assured […]
Read MoreCR389 Compulsory life annuity; commutation of monthly income payments
CR389 Compulsory life annuity; commutation of monthly income payments Compulsory life annuity – beneficiaries seeking lump sum payment instead of monthly income payments after death of annuitant before guarantee date – insurer stating that policy could not be commuted – whether there was any legislative or contractual impediment to payment of lump sum Background 1. […]
Read MoreCR388 Retrenchment/ interpretation/ contra proferentum
CR388 Retrenchment/ interpretation/ contra proferentum Policy excluding any retrenchment claim “where the retrenchment was announced within the first 6 months” – on the specific facts of this case, employer letter giving notice of proposed restructure and inviting consultation not an announcement of insured’s retrenchment – his actual retrenchment announced after expiry of the six month […]
Read MoreCR387 Prescription
CR387 Prescription Insurer mistakenly paying a cancer benefit in 2009 at a higher level than it should have been paid – insurer realising mistake when a claim for progression of cancer lodged in 2020 – insurer seeking to set off the new claim against the amount overpaid in 2009 – debt prescribed. Background: 1. The […]
Read MoreCR386 Termination of contract/ retrenchment claim
CR386 Termination of contract/ retrenchment claim Termination of long-standing contract/retrenchment benefit claim/consideration of form of employment. The background of the matter is as follows: 1. Mr W was employed at a State Department as an independent contractor, through a consulting agency, from 1 April 2010 up to 30 March 2017, at which time his contract […]
Read MoreCR385 Exclusion of psychiatric disorders; constitutional rights infringed?
CR385 Exclusion of psychiatric disorders; constitutional rights infringed? Background: 1. Mr X submitted a disability claim to the insurer based on a mental condition. It was declined by the insurer due to material non-disclosure at application for a history of this condition, supported by medical evidence. A psychiatric disorder exclusion was placed on the policy. […]
Read MoreCR384 Delay in payment; interest; in duplum rule
CR384 Delay in payment; interest; in duplum rule Background: 1. The policy commenced on 1 July 1995. It covered life, capital disability and a double accident (as defined) benefit each at R48 176. 2. The life insured Mr. V, a Police Officer, passed away as a result of a gunshot wound to the head on […]
Read MoreCR383 Disability claim – mineworker – hearing loss
CR383 Disability claim – mineworker – hearing loss Group scheme claim lodged in 2017 – insured passed fitness examinations and worked on mine for ten years before being declared unfit because of hearing loss – insurer declining claim on basis insured was already unfit for his position when first employed by mine in 2007 – […]
Read MoreCR382 Mistake, lapsing, reliance, reinstatement
CR382 Mistake, lapsing, reliance, reinstatement Lapsed policy – insurer informing policyholder that if arrears paid the policy would be reinstated, and mistakenly advising that this would be without underwriting if reinstatement took place before a mentioned date – policyholder paying arrears before mentioned date – insurer invoking its mistake – policyholder entitled to enforce contract […]
Read MoreCR381 Loss of income claim – Covid19 – is a TERS/UIF payment considered “income” in terms of the policy definition
CR381 Loss of income claim – Covid19 – is a TERS/UIF payment considered “income” in terms of the policy definition Background: 1. The policy commenced on 27 November 2017, after the National Credit Act (NCA) Regulations of August 2017 were promulgated. 2. The Policy stated: If you become Unemployed or if you are Unable to […]
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Our office provides an independent, objective, efficient and free service to policyholders and others in respect of their complaints arising from long-term insurance policies.
Our office provides an independent, objective, efficient and free service to policyholders and others in respect of their complaints arising from long-term insurance policies.
