CR376

Probabilities of Accidental Death for payment of Accidental Death Benefit

Accidental Death Benefit – insurer accepting death as accidental on probabilities – requiring actual proof that accidental to pay benefit

Background

1. The policy was a funeral policy which provided a funeral benefit of R5000 with an additional R5000 if the death was accidental.

2. The policy commenced on 1 July 2014.

3. The deceased passed away on 25 July 2014.

4. The death certificate noted the cause of death as “Under Investigation”

5. The preliminary post-mortem report noted “AWAITING RESULTS”. The results required, were the toxicology results.

6. The insurer obtained a report from a medical consultant who suggested that the cause of death was natural. He stated:

“Found dead in bed together with partner who woke up fine…Suggest: Natural causes…myocardial infarction…”

7. Based on this report the insurer declined the claim as the death was within the 6 month waiting period for death due to natural causes.

8. As the complainant had stated in the original complaint: “…the following day the two women, the other one my aunt both were found dead”, the office directed further enquiries to the investigating police officer.

9. The investigating officer confirmed that the photographs on the case file recorded the following: two women were found on the floor; both were deceased; one had signs of vomit from her mouth; the other did not; bowls next to the bodies showing what the deceased persons had eaten the night before.

Discussion:

10. We wrote to the insurer and stated that whilst it was possible that both of the deceased persons could have died as a result of natural causes on their own, given the circumstances under which the bodies were discovered, it was not probable that both people had passed away at the same place at the same time due to natural causes. On a balance of probabilities, it was more likely that the deaths were unnatural / accidental.

11. The insurer agreed to pay the funeral benefit as it accepted our view that the death, on a balance of probabilities, was accidental. It, however, wanted actual proof that the death was accidental before it would pay the accidental death benefit.

12. The insurer was advised that accepting, on a balance of probabilities, that the cause of death was accidental for payment of the funeral benefit was sufficient for payment of the accidental death benefit and that actual proof was not required.

Result:

13. The insurer paid the accidental death benefit.

GB
October 2017