Ombudsman denies disabled man's claim
Prithvirajh Singh, 54, a certified artisan who was employed as a maintenance manager for 12 years at a body corporate, was injured at work in May 2017.
After submitting identical documentation to both Discovery Life and Liberty Life insurance, he received his full payout a month later from Discovery Life.
Liberty Life Insurance, however, claimed that he is fit to work.
Singh held two life insurance policies with Liberty Life Insurance, one valued at over R5 million and the other for just over R900 000, taken out in 2009. Both have a capital disability benefit which is payable to policyholders in the event that they become permanently disabled.
“I am very sick,” said Singh. “On the day I got injured, I was in one of the units to fix water leaks. We were also putting in a spa bathtub with my colleagues which was being carried inside the unit. Unfortunately, the tub came flying down on me.”
Singh said he sustained injuries on his legs and arms and also suffered internal bleeding.
After the incident, he was assisted by Dirk van Deventer, who was chairperson of the body corporate of Sabuti at the time, to be medically boarded from his employment.
In a letter submitted to Liberty Life on Singh’s behalf, to assist the claim process, Van Deventer said: “His deteriorating health made it impossible for him to perform his duties in his employment.”
As a requirement, Singh also had an assessment done in July 2017 by an occupational therapist in Berea. He submitted various reports to the insurer from the therapist and an orthopaedic surgeon who said he was severely disabled and diagnosed him with proximal myopathy.
But Singh was told he would need to undergo an independent functional capacity evaluation by Liberty Life occupational therapist Shareen Kasolall.
Kasolall’s report contradicted all assessments previously done on Singh. In her report, she said Singh displayed skills required to perform duties of his occupation as a maintenance manager.
“Previous medical reports from his treating specialist have reported muscle wasting and weakness. This is not supported by objective evidence as per the functional capacity evaluation report, which indicates no loss of muscle mass and muscle strength within functional limits,” she said.
Based on her report, the claim was declined by Liberty Life, which said its client did not meet the criteria of being totally and permanently disabled for his own occupation. Singh then approached the ombudsman for assistance.
Sue Myrdal, assistant ombudsman, said she was not in a position to make a ruling on the matter before her. She said the dispute of facts, missing information as well as all the allegations put forward prevented her from doing so.
She further stated that “a claim must be decided on objective and complete medical evidence. Liberty Life Insurance is contractually entitled to call for additional information it may consider necessary to assess a claim if it is of the view that the information initially provided is inadequate or insufficient”.
Singh said the experience with Liberty Life Insurance had left him depressed and had caused his health to deteriorate further. He said he had done all that he could to ensure that he received his payout and that he had never missed a single instalment on both policies.
“I want what’s fair and my instalments,” said Singh.
Atusaye Mughogho, head of external communications and financial PR for Liberty Group South Africa, said Singh had approached the Office of the Ombudsman for Long-term Insurance to resolve this matter.
“A final determination was issued on November 28, 2019, and the ombudsman dismissed Mr Singh’s complaint. This determination confirms that Liberty exercised its contractual rights to decline the claims as the client did not meet the benefit criteria.”