Interpretation – activities of daily living cover – payable only if full time caregiver is required – meaning of ‘full time’

BACKGROUND

The complainant, a housewife, submitted a claim under the activities of daily work benefit after being diagnosed with chronic urinary retention as a result of bladder outlet obstruction with bilateral pyelonephritis.  She needs to perform clean intermittent self-catheterization every two to three hours.

To qualify for a claim in respect of the benefit, the complainant would, inter alia, have to comply with the following: “The claimant requires full time nursing care or a caregiver as a result of his/her medical condition.”

In her submission to our office the complainant explained as follows:

“My husband and youngest daughter are educators.  They return home daily at 3pm and relieve the helper (3 days in a week).

The days that I cannot afford a helper my niece takes care of me (2 days in a week).

On weekends my eldest daughter and husband who lives with me takes care of me (2 days).”

The following is an extract from a medical report submitted:

“The patient … finds that treatment with clean intermittent self-catheterization is very difficult and requires permanent assistance.  She needs to perform clean intermittent self-catheterization every two to three hours.”

The insurer declined her claim, as she “partially needs a caregiver to help catheterise, however does not require full time care.”

DISCUSSION

Our office wrote to the insurer and expressed the view that the meaning to be given to “full time” must be reasonable.  So, for example, it would be unreasonable to contend that “full time” means every second of the day.

Rather, a reasonable interpretation is to say that if a person requires nursing care or a caregiver to assist her on an ongoing basis for a very significant part of her day, then that would constitute “full time” case for the purposes of the policy.

The insurer did not agree with our view.  However, a meeting of the office’s adjudicators was unanimously of the view that the criteria had been met.

RESULT

A provisional ruling in favour of the complainant was therefore made which the insurer accepted.