CR334
Dread disease
Medical evidence not meeting criteria for claim on basis of stroke – claim repudiated – insurer asked to consider whether the evidence supported any other condition listed under “Nervous System” – insurer requesting neurologist report – complainant undergoing neurology assessment resulting in diagnosis of motor neuron disease – claim paid
Background
1. The complainant had a policy covering him for death, disability and dread disease, commencing on 1 February 2011. In May 2011 he fell and hurt his face. Subsequently he noticed that he had no feeling in his left index finger, his speech was slurred and his left leg dragged as he walked. He went to Addington Hospital and was put on daily aspirin treatment. An appointment was made for a scan, the earliest time available being three months later. When he had the scan in August 2011 there was no sign of a clot, but there were “features of age inappropriate cerebral atrophy”, as reported by the radiologist. He was under the impression that he had had a stroke, but that the clot had dissolved by the time he had the scan.
2. The complainant lodged a claim for a critical illness (dread disease) benefit, stroke being one of the conditions listed in the policy as covered under “Nervous System”. The insurer however repudiated the claim as the medical reports did not confirm the diagnosis of a stroke, and the condition of age inappropriate cerebral atrophy was not an insured event. The complainant lodged a complaint with our office.
Discussion
3. We accepted that there were no signs of stroke, but we mentioned to the insurer that various conditions were covered under “Nervous System” as well as stroke, including Altzheimer’s disease, dementia, benign brain tumour, Guillain Barré syndrome, Creutzfeld-Jacob disease, motor neuron disease, multiple sclerosis, muscular dystrophy and accidental brain damage amongst others. We asked the insurer whether the signs of age inappropriate cerebral atrophy would not fall within any of the other conditions listed under this category.
4. The insurer’s medical officer responded that the brain scan report indicated widespread signs of a shrinking brain, and involvement of the ventricular system, sulci and basal cisterns. He stated that this was typical of a chronic brain condition like senile dementia, Alzheimer’s disease, alcoholism or early age related atrophy. He proposed a neurologist assessment.
5. We pointed out to the complainant that while he might have one of the listed conditions, no such condition had actually been diagnosed and verified. The insurer was not prepared to pay for a neurologist assessment, correctly pointing out that the onus of proving his claim lay with the complainant.
6. The complainant then obtained a referral to Albert Luthuli Hospital where he was admitted for eight days for neurophysiological tests, MRI brain and spine scan, blood tests and lumbar puncture. Motor neuron disease was diagnosed.
Result
7. We sent the test results to the insurer. A claim for motor neuron disease was admitted and paid, in the amount of R715 000.
SM
February 2013
