CR18 Death claim rejected due to insurer’s reliance on pre-existing exclusion clause



The deceased’s credit life policy commenced on 6 June 2002. He died on 2 August 2002 as a result of cardiac arrest.

The insurer declined the claim due to its reliance on the pre-existing exclusion clause featuring in the policy terms and conditions. It stated that the deceased had suffered from diabetes mellitus prior to the commencement of the policy which contributed to the cause of death.

The office initially supported the insurer’s decision and the executor of the estate accepted the decision. The deceased’s son however did not accept our decision on the basis that he alleged that his father was never diagnosed with diabetes mellitus.


In support of its decision, the insurer initially submitted a PMA report from the deceased’s doctor who confirmed at the outset that diabetes mellitus was diagnosed on 2 May 2002 and that diabetes mellitus contributed to the cause of death. Such a diagnosis was subsequently denied.

Further medical information revealed that, one month prior to his death, the deceased suffered from symptoms of high blood sugar and a fingertip test was done indicating a glucose reading of 12mmg/ml. A change in diet was recommended at this stage. A day before the death the glucose reading was 4mmg/ml.

Further information received at dale of death stated that the immediate cause of death was cardiac arrest with aorta aneurysm and arteriosclerosis as underling causes of death. The insurer advanced that diabetes is a known risk factor for Arteriosclerosis.

In view of the conflicting medical information and the medical nature of the complaint, the matter was referred to an independent specialist for an opinion. The specialist upheld that, on a balance of probabilities, diabetes mellitus was a contributory cause of death. He advanced that this decision firstly required a diagnosis of diabetes mellitus before the commencement of the policy. This was confirmed by the deceased’s doctor reporting that symptoms of high blood sugar were experienced a month before the commencement date. Secondly, he reported that diabetes mellitus is a known risk factor in coronary thrombosis as well as arterial disease elsewhere in the body.
The insurer’s decision was upheld.