SERVICE: Income Protection
OUTCOME: Not upheld
Issues: Reasonable Decision – Initial Claim, Scope of cover
Mr T’s company held business disability cover for Mr T with the insurer.
In May 2023, Mr T made a claim for the total disablement (TD) benefit under the policy, because he had not been working since late January 2023, when he went overseas for his father’s funeral. Mr T said he was suffering from grief and post-traumatic stress disorder (PTSD) and a knee injury. Mr T’s doctor said Mr T had been diagnosed with PTSD in April 2023 and advised to take time off work in May 2023, with an expected return to work at the end of May 2023.
The policy had a 90 day wait period, which did not commence until Mr T consulted a doctor for the sickness or injury giving rise to the claim. Therefore, Mr T had to show he had been TD (unable to work and not working for more than 10 hours per week) for a period exceeding 90 days, in order to be eligible for the TD benefit. The insurer did not believe there was any medical evidence to show that Mr T had been TD for more than 90 days.
Mr T made a complaint, because he believed his medical history proved he was TD for at least 3 months between February and October 2023.
The case manager’s assessment
The case manager considered Mr T’s medical notes, and agreed with the insurer there was not enough evidence to support a period of TD for more than 90 days.
Although Mr T had provided a medical certificate saying he had been unable to work since March 2023, he had not consulted a doctor until April 2023, when the medical notes recorded “work is stressful but [Mr T was] ok”. While there was mention in his doctor’s notes that Mr T was not working in May 2023, a specialist’s report in June 2023 said that Mr T was very busy at work running his company. Further medical reports in August and September 2023 referred to Mr T working. In September 2023, Mr T’s doctor said that Mr T had told him he had been unable to work at least between April and June 2023.
While the medical evidence showed that Mr T had periods of unwellness due to PTSD and injuries, the evidence did not show a continuous period of TD for or exceeding 90 days, as required by the policy. Therefore, Mr T was not eligible to be paid a TD benefit and the insurer had correctly applied the policy terms and conditions to the claim.
Complaint No: 00230162