CR12
Disability claim – “own, similar or other occupation” – whether the complainant is suited for the alternative occupations the insurer maintains he is able to perform.
The complainant worked as a caretaker of community halls for a municipality. He had chronic bilateral osteoarthritis of the knee joints and had had total knee replacements. His services were terminated on grounds of incapacity and he submitted a claim for a disability benefit.
The definition of disability in the policy reads:
“The Company shall regard a Member as having become Disabled if…due to an injury, illness or a disease, he is totally and permanently prevented from following his own occupation, and a similar or other occupation for which he is suited having regard to his ability, training, education and experience.”
The insurer did not in dispute that the complainant could not perform his own occupation as a caretaker, which was a physically demanding job involving walking, bending to clean floors, lifting and carrying chairs, pushing a trolley, etc. However, the insurer maintained that he would be able to perform the duties of a clerk (he had worked as an office clerk before for a short period many years ago).
An examination of the complainant’s occupational history and current status, as set out in the occupational therapist’s report, indicated that, of his 27 years spent working, some 21 had been spent doing physical work: 3 years as a petrol attendant, 3 years installing electrical poles, 1 year as a packer and 14 years as a caretaker. Approximately 6 years were spent working as an office clerk, a number of years earlier (1978 – 1983), in our view making any skills he gained during that time out of date or forgotten to some degree. It appeared likely that he did not have a great aptitude for work as an office clerk, as his subsequent jobs, for the next 18 years, were manual jobs. His abilities and experience thus lay overwhelmingly in physical manual work. He had a relatively low level of education (Std 8) and no other training whatsoever. Our stated view was that in all the circumstances it was not reasonable to regard the complainant as suited for a clerical occupation.
The insurer objected to our preliminary view, stating that the fact that the bulk of the claimant’s work was manual was irrelevant, and reiterating that he had six years as an office clerk which would certainly be classed as experience.
We made a final ruling however that it was not reasonable to regard the complainant as suited for the clerical occupations mentioned. In the ruling we quoted from the LOA booklet “Impairment and Disability Assessment Guidelines” as follows:
“Factors which influence the reasonability of an alternative/similar occupation, include:
…
Years in current position. The lower one’s qualifications, and the longer one is in one specific occupation, the less reasonable will any alternative position become. In this regard it is recommended that it should be unfair to expect the following categories to do any alternative work, ie own/similar definitions should effectively become own occupation:
* Any manual labourer with qualifications less than Grade 12 at school, and doing a manual work for > 10 years”.
SM
