CR14

• Disability claim – insurer being pedantic

Background

Mrs A enjoyed an Income Protection Benefit from Company X. She was booked off from work for back problems. According to her general practitioner she should rest for 3 weeks and go for physiotherapy and biokinetic exercises. Two days later she instituted a claim but was informed that the claim was repudiated because she was not booked off by a specialist. She complained about this and Company X undertook to re-assess the claim. In the end it repudiated the claim because she did not go to a physiotherapist.

According to Mrs A, her doctor had advised her to rest and take medication, and only if that did not help, should she go for physiotherapy. When the three weeks expired she did go to a physiotherapist.

When we wrote to Company X it responded that the doctor’s instruction was not carried out. It also do no accept that a general practitioner could diagnose a serious back condition without referring the insured to a specialist. It relied on a clause in the contract which stated that “professional medical advice shall be sought and followed promptly on the occurrence of any bodily injury or illness and the company shall not be liable for that part of any claim which in the opinion of its medical advisor arises from the unreasonable or wilful neglect or failure of any insured person to seek and remain compliant under the care of a qualified medical practitioner”.

Assessment

We did not agree with Company X that Mrs A did not carry out the doctor’s instruction or that the doctor’s advice could be interpreted that she should immediately go for physiotherapy. We also did not agree that the abovementioned clause could be interpreted that she should consult with a specialist before a valid claim could be instituted.

Result

Company X decided to pay the benefit.

AS