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PFA ruling regarding the manner in which trustees excercise their discretion

15 April 2008 Pension Fund Adjudicator

RULING BY THE PENSION FUNDS ADJUDICATOR ON THE MANNER IN WHICH TRUSTEES OF FUNDS MUST EXERCISE THEIR DISCRETION WHEN CONSIDERING MEDICAL REPORTS IN THE CONTEXT OF GRANTING OR DECLINING DISABILITY BENEFITS

The Pension Funds Adjudicator has issued a ruling in the matter of H v Bidcorp Provident Fund & Alexander Forbes regarding the fact that Trustees of funds must in the exercise their discretion on whether or not to grant a disability benefit, consider the medical reports fully and not place reliance on reports with factual inaccuracies and inconsistencies which bring the medical correctness of the report into question.

Summary of Facts

The complainant in this matter was employed by Safcor Panalpina as a forwarding clerk. She was diagnosed with sarcoidosis, a lung disease and according to her and the supporting medical reports she is unable to go back to work and as such she has requested this tribunal to make a ruling on her disability claim. The respondents were adamant that she does not qualify for a disability benefit. The medical experts that examined the complainant are Ms W, independent Occupational Therapist and thereafter her records were referred to Dr D also a Physician so that she could assess the medical records. The insurer, Old Mutual, then considered the assessment of the Complainant’s medical records by Dr D and repudiated the claim.

The complainant approached this tribunal contesting the factual accuracy of the medical report that formed the basis for the insurer’s decision to repudiate the disability claim.

The Adjudicator found that what is crystal clear from the rules is that, the Trustees, have a duty to determine whether or not a member is permanently incapable of efficiently discharging her duties through infirmity of the mind or body premised on medical advice.

The Adjudicator noted that the medical advice relied on by the respondent was the report of Ms W and Dr D. On analysing Ms W’s report, it became apparent that the report had factual inaccuracies that could have an impact on the medical assessment.

The inaccuracies and inconsistencies identified were the following:

  1. Date of birth of the complainant is identified as 10 April 1977 and in the same report the complainant is alleged to have completed Grade 10 in 1976, before she was born.
  1. The report signature date is 11 July 2007 whereas it refers to a report dated after the date of signature which is 17 July 2007 and 23 October 2007.
  1. Further Dr D is said to have discussed the complainant’s medical condition with Dr P, a specialist, in July and Dr P had indicated that the complainant could return to work but Dr P in his written report dated 25 July 2007 recommends the exact opposite.

Held:

The Adjudicator, due to all the above inconsistencies and inaccuracies ruled that the medical report could not be relied on and had to be reviewed and as such the decision of the trustees premised thereon similarly could not stand.

In the result, it was ordered that:

  1. The Trustees decision be set aside.
  1. The first respondent was directed to refer the assessment report of the complainant for corrections and amendments by Ms W or an alternative independent Occupational Therapist, as the case may be, within 30 days from the date of the determination.
  1. The Trustees were ordered to exercise their discretion and make a determination in terms of rule 30.1 on the ability of the complainant to discharge her duties within 14 days after receiving the assessment report from the Occupational Therapist.
  1. The decision by the Trustees together with the assessment report should be communicated to the complainant, the insurer and the Office of the Pension Funds Adjudicator within 14 days of receipt of the assessment report.

Click here to read the full determination (PDF file 92kb)

 

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