CR216
Disability – definition of disability – housewife as an occupation

Background

The complainant was the owner of a policy that offered, inter alia, occupational and physical disability benefits. When the complainant applied for the policy she indicated her occupation as “housewife”. The insurer accepted her application and issued the policy.

She instituted a disability claim after she was injured in an accident and could no longer perform her daily responsibilities as housewife. The insurer assessed her disability under physical disablement (and not occupational disablement) and repudiated the claim because her disability did not in its view fall within the definition of physical disablement.

When we asked the insurer why it did not assess her in terms of the occupational disability definition, the insurer stated that in order to qualify for occupation disablement she would have to be unable to perform her usual occupation or any other occupation that she could reasonably expect to follow having regard to her education, training, knowledge, ability and age. In casu, according to the insurer, no similar occupation exists and hence she could not be assessed for occupational disability.

Discussion

We discussed the complaint at an adjudicators’ meeting. Our opinion was as follows:

• Our understanding is that when occupational disability was initially introduced housewives were not granted cover.

• However, with the passage of time housewives were covered, provided that the insured amount was not excessive.

• The usual practice was to amend the definition of disability to the effect that to qualify the insured would have to be confined to home under medical supervision or to a hospital or similar institution; or unable to perform a number of activities of daily living (bathing, going to the toilet, etc.) without the assistance of a third party.

• In this instance the insurer accepted the application for, inter alia, disability benefits, knowing that the applicant was a housewife. Furthermore, the definition for disability did not change.

Result

We instructed the insurer to assess the claim for disability under the occupational disability definition. The insurer abided by our decision, sent the complainant for an assessment by an occupational therapist and, upon receipt of the report from the OT, admitted the claim and paid an amount of R55 850 to the complainant.

AS
May 2007