CR240

Disability

Assessment – occupation was 30% manual – complainant still able to perform most aspects of his occupation, but could not perform any manual work as result of permanent irreversible incapacity – settlement on basis that insurer would pay 50% of capital disability benefit assured.

Background

The complainant jumped out of a third floor window to escape an attacker. He shattered his heel bones and fractured his left wrist. After surgery he was unable to walk for more than five minutes before needing to sit down, and his ability to stand was also restricted.

The complainant was a sheet metal worker, and ran a business that manufactured switchboard panels. At the time he took out the policy he stated his duties to be 50% manual and 50% supervisory; at claim stage he advised that his duties had been 30% manual, 20% administrative, 10% travel and 40% supervisory.

A specialist surgeon assessed the complainant’s functional impairment for the insurer. He reported that the damage to the complainant’s subtalar joints meant that his feet would be painful for the rest of his life. He felt the complainant’s symptoms were somewhat exaggerated, however, and that with high-topped boots and callipers he would be able to get out of his wheelchair and supervise his business: “In other words, I believe his business can go on as before, except that he would not be able to participate in any ‘hands-on’ labour. He would only be able to function in a supervisory capacity”.

What was required in terms of the policy, to qualify for the capital disability benefit, was permanent, irreversible incapacity, which resulted in the life assured being unable to perform his own occupation or any other suited occupation that he could reasonably be expected to carry on taking into account his standard of education, training, experience and ability.

The insurer rejected the claim on the grounds that the injuries did not result in the complainant being unable to perform his own or a suited occupation; according to the insurer, furthermore, by applying basic rehabilitative devices he should be able to perform most of the functions of his occupation. The insurer also provided a forensic report indicating that the complainant was in fact at work every day.

The complainant admitted that he was at work daily, but stated that he had to keep the business going to take care of the needs of his family. He was in severe pain every day, however, and could not physically manage working with heavy sheet metal – marking, cutting, bending, welding, washing, and assembling. He could not afford to employ a qualified sheet metal worker, but had had to employ two cheap labourers and to try to show them what to do.

Discussion

We accepted that the complainant was able to perform most aspects of his occupation. He had permanent damage to his feet, however, which would cause him pain for the remainder of his life, and the medical opinion was that he would not be able to participate in any ‘hands-on’ labour. It was obvious that manual work was still a necessary and significant part of the complainant’s occupation, work which he could no longer do. Accordingly we requested that the insurer make an offer to pay a proportion of the capital disability benefit.

Result

As a gesture of goodwill the insurer agreed and made an offer to pay 50% of the sum assured, an amount of R134 000. The complainant gladly accepted it.