Ombudsman for Long-term Insurance determination against PPS

The Office of the Ombudsman for Long-Term Insurance has issued a final determination against the Professional Provident Society Insurance Co. Ltd (“PPS”)

The determination is attached.

SUMMARY

Background

1. The complainant is a 59 year old dentist who has had a PPS policy for an extensive period of time. He suffers from:

· Chronic ischaemic heart disease with previous myocardial infarctions,
· Angina pectoris,
· Hypertension,
· Gout,
· Hypercholesterolemia,
· Loss of vision in one eye.

He stopped practising as a dentist and submitted a claim to PPS and they paid his Sickness benefit for two years. Subsequently the insurer considered him for a Partial Permanent Incapacity award and assessed him to be 20% Partially Permanently Incapacitated.

2. To be considered for this benefit the claimant must be “permanently but not totally unable to carry out his own profession as well as any other profession that could be carried out by persons with similar or comparable qualifications.” In terms of PPS’s policy the benefit is paid out as either 20% or 60% of the insured sum.

3. The complainant was dissatisfied with the decision to pay him only a 20% benefit and lodged a complaint with the office.

4. The insurer took the view that the complainant was in fact still practising his profession on a partial basis. This was in response to the complainant stating that he occupied his day in part by “Developing managed health care programme for African continent.”

5. PPS also contended in response to the complaint that the complainant could practice as a clinical dentist, albeit not on a full day basis.

6. PPS further contended that the complainant had not been on maximum medical intervention as required in terms of the policy.  

7. Medical information

• The medical evidence indicated that the complainant had suffered two myocardial infarctions and that he had extensive coronary calcification involving major coronary arteries but that his left ventricular systolic function was in the normal range. He had opted not to undergo repeat coronary angiography with the view to revascularisation, likely in his case to be a coronary bypass operation.
•  In the ophthalmic surgeon’s opinion, because the complainant had reduced visual acuity of 6/60 which gives loss of binocular visual acuity and most importantly loss of depth perception, he was effectively functioning with only one eye. According to the ophthalmic surgeon this is a severe handicap in the complainant’s profession as a dentist as “it would be very difficult to position instruments accurately particularly when working at the back of the mouth” and in his view the complainant was totally unfit to perform his professional duties as a dentist.
•  According to the report by the occupational therapist and physiotherapist, who could not comment on his visual acuity, the complainant could cope for three hours with the physical demands of dentistry but only if he should “take regular rest breaks during that three hour period”.
•  The complainant presented with Acute Coronary Syndrome followed by triple stent insertion in May 2009.

8. In response to our provisional determination in favour of a 60% benefit for the complainant, PPS confirmed their previous decision that the complainant only qualified for a 20% benefit.

Final determination

9. We did not find PPS’s arguments convincing.

10. We determined that the complainant could not practice as a clinical dentist due to his medical condition.

11. His voluntary work in a project to make affordable health care available for people across Africa was not regarded by the office as practising his profession as a dentist. There was no indication that this was a money making venture and it was in any event not a profession. It appeared to be an altruistic project which the complainant was pursuing out of interest.

12. In our view the policy did not require maximum medical intervention. On general principles an insurer could not expect a claimant to have undergone anything more than adequate medical treatment. In our view the insurer had not shown that the medical treatment the claimant had undergone fell short of this.

13. We were of the view that the complainant could still pursue non-clinical work using his professional qualifications but not on a full-time basis.

14. We determined that the insurer should pay the benefit at the rate of 60% instead of 20%.