CR95
Funeral claim declined – maximum age attained – not a full time student – accommodating attitude of insurer
Background
The policyholder was in receipt of two funeral policies held with two separate insurers covering the parents’ lives and that of their teenage son. The provisions of the policies provided for the following: Insurer A;
(i) Sum assured of R3 000 without bonuses payable on the death of each Life Assured should this occur before his/her twenty-first birthday.
(ii) Sum assured of R3000 without bonuses payable on the death of each Life assured should this occur on or after his/her twenty-first birthday but before his/her twenty-sixth birthday provided that he/she is a full-time student at a public educational institution and wholly dependent upon the Assured for his/her maintenance.
Insurer B;
A child must be unmarried and:
(i) Under the age of 21; or
(ii) Under the age of 25 and undergoing full-time education approved by the employer; or
(iii) Accepted by an Employer as permanently incapacitated by physical or mental infirmity from supporting himself.
The insured son passed away 10 days after his twenty-first birthday and both claims were declined on the grounds that the deceased did not qualify in terms of the relevant provisions. It was also confirmed that the deceased was employed on a full-time basis.
Assessment
In view of the provisions provided by both insurers we informed the complainants that their claim could not be upheld as the insurers decisions were justified and in line with the provision of the contracts. The policy held with insurer B had been in force for less than 2 years. We did, however, inform the complainants that we would approach insurer A to adopt a more sympathetic approach in this instance (a) given the short period of 10 days in question, (b) the insured amount involved and (c) the fact the complainant was a long-standing policyholder with their company.
Recommendation
Insurer A was requested to consider paying the claim or a substantial part thereof on an ex-gratia basis.
Resolved
The full amount of R3000 was paid to the insured. We expressed our appreciation to the insurer.
DCW
October 2005
