Insurance ombudsman: annual reports for disability reasonable

The Ombudsman for Long-term Insurance, Judge Ron McLaren, has upheld a complaint against Sanlam for requesting frequent reports to support a claim for income disability benefits and ruled that an annual review would be reasonable.

The ombudsman said an annual review was reasonable considering that one of her doctors stated that her clinical condition has deteriorated with the neuropathy affecting a bigger part of her lower legs, causing a high level of pain. However, with adequate pain control, she could work, though it has not been achieved. She also has a problem with side effects of the pain medication and the other comorbidities.

According to Sanlam, medical validity of a claim can be accepted before maximum medical improvement is reached for income protector benefits, unlike lump sum disability benefits. Its medical team would be guided by the client’s specialists’ assessment of the disease process, medical management and prognosis.

“However, the specialists have not noted that MMI has been reached and neither have they removed the possibility of Ms D returning to work. Their conclusion remains that with adequate control of the problem there is a possibility that Ms D can still function well in the working environment,” Sanlam said.

Sanlam said it acknowledged the consumer’s burden of disease that currently makes her unable to work and therefore accepted the validity of the income protector benefit claim for the next six months, but requires follow-up reports as part of her routine medical management that is already part of her routine medical management.

While the ombudsman accepted the right of Sanlam to request the reports, he pointed out that is has to be exercised reasonably. His final determination was therefore that Sanlam can request medical reports annually, but not more frequently than that.

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