CR218 Disability – income benefits terminated


Disability – income benefits terminated – policy cancelled – insured allegedly not taking prescribed medication

1. The complainant was granted permanent incapacity benefits by the insurer as she was disabled due to a psychiatric disorder.

2. During interviews with staff of the insurer, which included their medical officers, she was cautioned to take the medication as prescribed by her psychiatrist. This warning came after the insured indicated (according to the insurer) that she was reluctant to take the prescribed anti-depressants. (The treating psychiatrist also made mention of this reluctance in his report.)

3. When the policyholder was again interviewed by the insurer she indicated, according to the insurer, that she did not believe in the use of anti-depressants as this offended her religious beliefs. She was again told to start using the medication and given six months to do.

4. The insurer thereupon invoked a specific clause in the contract to cancel her benefits and subsequently cancelled her policy. The clause in question states that the benefits could cease if the insured “…..aggravates his condition by excessive smoking or by excessive indulgence in liquor or drugs or by neglecting to carry out the instructions of his medical attendant ….”

5. The complainant suffered from major depression to a serious degree with chronic and mood congruent psychotic features. She also had panic disorder with agoraphobia (fear of public or open spaces).

6. The complainant lodged a complaint with our office.

7. The complainant denied to us that she had indicated that she did not believe in pharmacological interventions. She alleged that she simply raised generally concerns about the effectiveness of long term medication with her doctor and the problems that pharmacies experienced at the time. She alleged that she used the prescribed medication. She also used the spiritual aid of prayer in combating her illness.

8. After an extensive delay the complainant was able to produce some proof of purchasing medication although she could not provide proof of continuous use of the medicine.

9. The insurer made an offer to the complainant after the production of the evidence to pay a reduced benefit for the period in question but the offer was not accepted.

10. The difficulty which we experienced with the complaint was that the mental condition of the complainant made her difficult to deal with and we were not certain how her mental condition impacted on her ability to function in all spheres of life including the efficient use of medication, the submission of her complaint and her interaction with the insurer. The complainant had at one time made threatening comments to our staff members.

11. We wrote to the complainant suggesting that she give further consideration to the insurer’s offer as she had not been able to provide evidence that she had been using the medication prescribed by her doctor continuously. We further pointed out to her that the matter was fairly evenly balanced because the insurer had not provided us with a medical opinion that in her specific case the non-use of the medication (during the months when she could not produce evidence of purchase) would have aggravated her condition. However, if the insurer produced such evidence after a provisional ruling in favour of the complainant there would be a risk that the ruling would go the other way. We therefore asked her to reconsider the offer.

12. After further consideration and a discussion with her attorney the complainant agreed to accept the offer.

May 2007