CR403 – Pre-existing condition clause in disability benefit

Pre-existing condition clause in disability benefit– time limit on conditions excluded – onus on insurer to prove the pre-existing medical condition existed within the time frame and its causal link to the disability

The complainant was employed by the employer as long-haul truck driver in July 2016. On 1 November 2016 he became a member of the union’s Provident Fund and an insured under the fund’s group risk policy.

A claim for disability benefits was submitted to the insurer in February 2018 following the complainant being declared unfit to work as a result of “anterolisthesis and spondylosis with ischiatic nerve irritation, with referred pain to the left leg associated with weakness”. The date of disability was determined to be 1 July 2017.  The insurer declined the claim because the complainant’s “disability was traceable to a condition of which symptoms (weakness and referred pains in his left leg) were experienced in the six months before his cover started.”

The insurer relied on the medical report dated 6 November 2017 in which the doctor stated: “(The claimant) was involved in a train accident 2003 and injured his lower back. He was suffering since 2003 with chronic lower back pains and since 2017 experienced the weakness and referred pains his left leg.”

The policy stipulated that a benefit is not payable if the insured becomes totally disabled within 12 months of commencement of cover if the disability is directly or indirectly traceable to:

  • a bodily injury which occurred, or
  • a condition of which the INSURED was conscious or experienced symptoms for which medical treatment was received during the six MONTHS immediately before the mentioned date.”

We pointed out to the insurer that the complainant’s cover commenced on 1 November 2016.  According to the doctor, the symptoms referred to (weakness and referred pains in his left leg) only commenced in 2017.  The history of consultations shows the first date of consultation as 8 March 2017.  This appeared to be corroborated by the report of another doctor dated 10 July 2017, which states that the patient reported a 5-month history of worsening lower back pain.

We also pointed out that a “Road Traffic Act” medical report was completed on 23 June 2016, seemingly as part of the requirements to obtain a driver licence to drive a heavy duty vehicle, wherein the question of whether the complainant, to the best of the doctor’s knowledge, suffered from any condition causing muscular incoordination, was answered in the negative, and the complainant was given a clean bill of health for the purposes of driving a heavy duty vehicle.

Whilst we acknowledged that the insured suffered a back injury in a train accident in

2003, seemingly to the lower back, we were not convinced that the insurer had discharged the onus of proving that in the six months prior to commencement the insured had a condition of which he was conscious or experienced symptoms for which medical treatment was received.  We did not think a broad statement “since

2003 chronic lower back pain” was sufficient to prove on a balance of probabilities that the condition (of chronic lower back pain) occurred in the six months prior to the commencement or that the insured was conscious of the condition in those six months.   We therefore asked the insurer if there was any medical or other evidence specifically pertaining to the six months prior to the commencement to support their contention that the insured had a pre-existing condition as described in the “pre-existing condition” clause.

In response, the insurer decided to admit the claim and the benefit of R267 562 was paid to the fund, for the benefit of the complainant.

This case demonstrates that an insurer has to provide the medical evidence required to prove, on a balance of probabilities, the pre-existing medical condition and its causal link to the claim event.