Mr X from Benoni spent two months in ICU before dying of “unknown causes”.
His estate was being administered by one of South Africa’s top companies, and RC consulted with said company throughout, who granted us permission to proceed on their behalf with the different insurance companies and the Long Term Ombudsman specifically. RC then gathered medical information from the two private hospitals involved, and further forensic investigations were conducted with the doctors and specialist involved.
Policy Coverage taken out by the insured party :-
- Group Scheme Cover R880 000 – Death Claim
- Annuity R250 000 – Death Claim
- Death Cover Claim – R1 000 000
- Comprehensive Disability and Impairment – R1 200 000
- Comprehensive Critical Illness Benefit ( Severe Illness Benefit – R500 000
- R105 000 interest and the above claims paid nine (9) months after his death
The insurers repudiated some of the claims at first, alleging that benefits like Disability, Impairment and Critical Illness are nullified at death. RC did several further submissions, and proved that these events took place before the deceased passed away, and that the claims were valid within the specified periods.
The insurers involved external specialist consultants in an effort to prove their case for repudiation. The Long Term Ombud then made a provisional ruling in favour of RC, and made a final ruling that the insurers must pay the claims, since the client qualified on both contracts before his death for the Impairment and Critical Illness Benefits.
The insurers were forced to accept the ruling, but only elected to pay out R55 000 in interest. RC resubmitted the case to the Ombud and referred both the insurers to the LOA (Asisa) standards and protocol on the reasonable period to settle a specific claim category and also on the amount of interest they should pay. The insurers then settled on a payment of R105 000 in interest.
RC successfully closed the case.