CR15

Disability – suitable alternative occupation

Facts

The insured in this case was a saleslady in the fresh produce department of a small supermarket. She started suffering from repeated hernia complaints for which she had six repairs during a period of five years. As a result her employer “boarded” her after they had attempted to redeploy her to delicatessen department. Here she was still required to lift packages and she became acutely ill and the employer thereupon terminated her employment. The employer also indicated that the insured was unable to stand for extended periods and presented with excessive abdominal and lower limb swelling by the end of the working day. When she submitted a disability claim to the insurer the insurer declined the claim on the basis that although the complainant could no longer fulfil her previous occupation she could work as a saleslady in the fresh produce department of a different kind of supermarket or she could work as a cashier.

The complainant was 46 years old and had a standard seven education and had worked as a saleslady in the fresh produce department since commencing employment. In the light of her physical disabilities we requested the insurer to re-evaluate the complaint. The definition of total and permanent disability which applied to her policy read as follows: “the normal occupation in which the life assured was gainfully employed at the time of disablement or any other occupation for gain or reward to which the life assured would be reasonably suited by education, training, earnings, status or experience.”

Discussion

We were of the opinion that the alternative occupation for which the complainant would be able to qualify would require extensive accommodation by an employer to such an extent that we were not convinced that such occupations existed in reality. As she was unable to lift objects, unable to stand for extended periods and according to her previous employer did not have the intellectual capacity to work as a cashier that left a very limited number of occupations available to her. We were not convinced that these fell within the purview of the definition. A claims consultant from a reinsurer re-evaluated the claim and submitted that it was unlikely that any new potential employer would willingly tailor-make a position to suit the complainant and conceded that it would be unreasonable to decline the claim on the basis that the complainant could carry on an alternative occupation. The insurer accordingly paid the claim.

JP