Exclusion – Insurer relied on several exclusions to avoid payment – suicide exclusion – deliberate exposure to unnecessary danger
Background
- The life insured had a policy with cover for female cancers and accidental death since March 2005. On the evening of her death, she took her prescribed depression medication, which included a sleeping pill, and thereafter drew a bath. She subsequently (allegedly) fell asleep in the bath and drowned.
- The complainant, the deceased life insured’s mother, submitted a claim in June 2014. The insurer advised the complainant that it required the results of the post mortem report before making a decision whether to pay out the claim.
- It took two years to obtain the post mortem report. When obtained, the report stated that the cause of death was found to be “in keeping with drowning in a patient with toxic/lethal drug levels.”
- Based on this report, the insurer initially declined the claim relying on the suicide exclusion in the policy:
- “Exclusions
11.2. The accident lump sum shall not be payable if the accidental death of the life insured is caused directly or indirectly by or results from –
11.2.1. Suicide or any attempt thereat by the life insured (whether sane or insane)”
- After the complainant approached our offices, the insurer reviewed the matter and advised that it could possibly rely on exclusion 11.2.2 as the basis of the decline, as claims were excluded if the cause was:
“consumption by the life insured of alcohol, recreational drugs, narcotic drugs, habit-forming drugs or dependence-producing drugs, except, in respect of all the aforementioned, as bona fide prescribed by a duly qualified and registered medical practitioner;”
- The toxicology report, submitted with the post mortem report, indicated that at least two anti-depressants, a narcotic and over-the-counter medication such as an anti-histamine and paracetamol, were found in the insured’s blood. This was not disputed – it was accepted that the insured took medication before she got into her bath.
- The insurer also relied on exclusion 11.2.4:
“intentional self-inflicted injuries or deliberate exposure of the life insured to unnecessary danger”
- The insurer was of the view that the insured “ingested a cocktail of antidepressants and entered the bath tub. This, to the reasonable person, may be viewed as deliberate exposure of the insured person to unnecessary danger.”
- Accordingly, the insurer declined the claim.
Discussion
- We did not agree with the insurer, and over the course of several telephone calls we discussed possible scenarios.
- We pointed out to the insurer that the mere fact that a person gets into a bath, even when that person took prescribed medication, cannot be said to be a deliberate exposure to unnecessary danger. If that view is to be accepted, then a person taking a shower, and slipping on wet tiles, can be said to have wilfully exposed himself to unnecessary danger. Every time a person gets into a motor vehicle, he or she is deliberately exposing himself or herself to unnecessary danger. Should people then not get into showers or baths or motor vehicles, because it may be dangerous to do so?
- The insurer acknowledged our views, but was however adamant that the insured had taken a lethal dose of medication which, in the insurer’s view, was of a significant level and would thus amount to an “unprescribed” amount from her doctor. We accordingly requested a copy of the insured’s most recent prescription.
- The complainant provided a report from the insured’s doctor, who specified the medication prescribed to the insured. The medication included antidepressants, anti-inflammatories and mood stabilisers.
- The complainant further provided WhatsApp messages from the insured’s cell phone to her partner. These messages did not indicate any intention to cause harm to herself, the insured stated that she needed to take a bath as she was very cold, but she would respond to her partner’s messages after her bath.
Result
- The insurer found the information most helpful and reviewed the claim again. It decided to pay the claim.
