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medical-aid

Claims and Medical Opinions

The Long-term Ombud’s Ombuzz Issue 33: April 2016 contains some very interesting case studies on the role of medical opinions when claims are repudiated.

In many complaints our office has to deal with medical evidence. At times we need assistance from a medical expert in order to resolve the issues. Such assistance is in the form of an opinion by an expert but the office still makes the complaint decision. This is because it is a legal question whether the claim requirements of a policy have been met, or, whether an insurer can rely on an exclusion clause, or, whether an insurer can repudiate a policy based on non-disclosed information.

The case studies published in the newsletter demonstrate some interesting/unusual medical questions that were resolved with the assistance of medical experts. Some of the medical reports are very technical and the office would not be able to make a correct evaluation without the assistance of a medical expert.

Case Study 1

Mrs B lodged a complaint as she was not satisfied with her insurer’s decision to decline her claim which was based on a second trimester miscarriage.

Case Study 2

The beneficiary’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 as required by the policy.

Case Study 3

The complainant’s claim for an impairment benefit and/or a dread disease benefit was repudiated by the insurer, on the grounds that her condition did not fall within the ambit of any of the covered conditions on her policy.

Case Study 4

The complainant had a policy that provided cover inter alia for cancer. She underwent ovarian surgery, as malignancy was suspected. A claim was submitted, but the insurer declined the claim.

Please click here to access full details of the four case studies

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