Insurance Ombudsman rules insurer must acquire supporting documents

14 December 2020 The office for the Ombudsman for Long-Term Insurance
Judge Ron McLaren, Ombudsman for Long-term Insurance

Judge Ron McLaren, Ombudsman for Long-term Insurance

If an insurer wishes to rely on an exclusion, then the onus of proof is on the insurer who must obtain the evidence on which it wants to depend.

This was stated by the Ombudsman for Long-term Insurance Judge Ron McLaren when he upheld a complaint against AIG Life which insisted that the policyholder must provide documents.

The complainant claimed in terms of a hospital cash plan policy for hospitalisation for cellulitis. AIG Life “pended” the claim while awaiting documents from the complainant to rule out diabetes as the cause of hospitalisation, as that is an exclusion in the policy.

The complainant is a known diabetic. The complainant was not prepared to provide the documents and lodged a complaint. The requested documents could only be obtained by a physical visit to the hospital.

The complainant who is a pensioner said: “The crux of the matter is that I am being given the run around to obtain a mountain of records from the hospital. I stay in rural Lydenburg. The hospital is 130km away in Nelspruit.

“In the past a letter from the admitting doctor sufficed for a claim. Now I have to obtain ward reports and blood testing reports. This was never the case and it seems that the claim is being made difficult just to discourage me from claiming.”

The Ombudsman took the stance that if AIG Life wished to rely on an exclusion such as diabetes, AIG Life had to obtain the necessary evidence to count on. There was no responsibility on the claimant to prove that she was not treated for diabetes. If the insurer wanted to prove that the condition for which she was treated was diabetes-related, then the insurer must prove it.

The insurer explained its requirements as follows: “… the claim information indicated that the diagnosis was bilateral lower limb cellulites, diabetes … the insured was treated for diabetes which is an exclusion; therefore, we require the documents to conclusively rule out diabetes…”

The Ombudsman informed the insurer: “When a claimant claims for a benefit under a policy, the claimant has to prove his/her claim. This is done by proving the event which is insured. In this case the claimant is claiming for hospitalisation. The claimant has to prove that she was necessarily hospitalised. That is all. ‘’

AIG Life was adamant and insisted “our policy wording is clear around the onus of proof and the claims conditions refer to an insured providing all documentation at the insured’s cost”.

The Ombudsman responded that the evidence indicated that the complainant was admitted and hospitalised for cellulitis and, as such, that her claim fell within the scope of insurance. The insurer had not alleged at any stage that the complainant’s claim did not fall within the scope of insurance.

“If AIG Life wishes to rely on the diabetes exclusion, it has to obtain the evidence necessary to prove that the hospitalisation was as a result of, by, for or from diabetes. It cannot ask the complainant to provide that evidence.

“The fact that the complainant is a known diabetic who was treated for cellulitis is not sufficient to discharge that onus. AIG Life has not made out a prima facie case that the complainant was hospitalised as a result, by, for or from diabetes. The documentation reflects that she was hospitalised as a result of, or, for Cellulitis.

“The fact that she has an underlying condition of diabetes does not bring her within the exclusion clause.”

In his final determination, the Ombudsman ruled that AIG Life must not expect the complainant to provide the medical information it requested. It must obtain the information itself.

AIG was given 30 days to obtain the information and make its claim decision known, or, it must pay the claim. The insurer paid the claim of R3 000.

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