A woman whose insurer rejected her claim for a total permanent disability (TPD) benefit has had her case upheld by the Insurance and Savings Ombudsman.
The woman claimed the benefit after having a heart valve transplant. But following a review of medical evidence from her cardiologist and an occupational medicine specialist, the insurer said it did not believe she had a TPD.
The office of the ISO, which outlined the case in its latest annual report, said it examined whether the insurer’s decision was reasonable and made in good faith.
The woman’s cardiologist said he believed her heart condition had caused a TPD and she couldn’t return to work. However, the occupational medicine specialist said the woman’s inability to work might have been caused by asthma or anxiety attacks. But he said further examinations from a respiratory physician and psychiatrist were needed to make a final judgement. These further examinations never took place. The ISO said the insurer hadn’t provided enough medical evidence to disprove that the woman had a TPD. In her cardiologist’s opinion she had a TDP and her claim should be met.
In another case, an insurer stopped paying a woman suffering mental health problems a total disability allowance after four years. It ended the payments after receiving a report from an independent psychiatrist. However, the woman did get a “recovery benefit” equal to three months of TD benefit.
The woman argued there was no medical reason to end the benefit. She believed she had a TD because she couldn’t return to her old job and hadn’t undergone rehabilitation to enable her to retrain.
Again the ISO said it looked at whether the insurer’s decision was reasonable and made in good faith. The woman’s psychiatrist believed she could return to work for up to 15 hours a week, which could gradually increase. Another psychiatrist took a similar view.
The ISO said the medical information showed the woman didn’t have a TD so it turned down her claim. Her claim for a partial disability benefit was also rejected. Under the terms of her policy she had to be in part-time work to be eligible for a PD benefit and she was not.
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