SA Income Protection and PTD Claim

[Tantravaya]

My son lodged a claim with his income protection insurer after being injured (disc prolapse) on a fishing boat while working. His claim was accepted and he has been paid an income stream for nearly 2 years. He has now lodged a claim for the small PTD portion of the policy as he is unable to go back to work - either his old job or another job he has skills experience or training for. His PTD claim has been refused as they now say his disc prolapse was caused by degeneration which is specifically excluded in his policy. Yet, the income protection payments were accepted despite degeneration also being excluded on that portion of the policy. The issue of degeneration wasn't brought up then. Can they turn around now and say he is not entitled to a lump sum payment despite already paying him income payments for the same medical condition. He meets all the criteria of the policy for the PTD payment. His position is that he suffered a trauma that caused the injury, not degeneration.

 

[Tim W]

That may be his position, but it will be a matter of medical evidence.

I suggest making contact with a lawyer who works in the Personal Injury space,
for case specific advice.

It may also be helpful to find out if he has any TPD-like cover associated with his (compulsory) super.

 

[Zerojay]

Has the insurance company provided an explanation? If not, ask for one. A lot of problems are caused by simple poor communication. They need to give reasons to substantiate the decision and apparent inconsistency. For example the policy may consist of two sections with different conditions/exclusions.

I do not give legal advice. Just my opinion based on working for an insurance company for over 20 years.

 

[Owais]

My son lodged a claim with his income protection insurer after being injured (disc prolapse) on a fishing boat while working. His claim was accepted and he has been paid an income stream for nearly 2 years. He has now lodged a claim for the small PTD portion of the policy as he is unable to go back to work - either his old job or another job he has skills experience or training for. His PTD claim has been refused as they now say his disc prolapse was caused by degeneration which is specifically excluded in his policy. Yet, the income protection payments were accepted despite degeneration also being excluded on that portion of the policy. The issue of degeneration wasn't brought up then. Can they turn around now and say he is not entitled to a lump sum payment despite already paying him income payments for the same medical condition. He meets all the criteria of the policy for the PTD payment. His position is that he suffered a trauma that caused the injury, not degeneration.

Hi Tantravaya - this is a common problem with life insurance and policies. Given the limited facts you have provided, Insurer may be liable to accept the PTD claim (if all the other criteria has been met) if they have accepted his Income Protection which had the same exclusion of degeneration clause.

Also Insurer maybe under the impression that your son's claim is based on degeneration but not trauma. I suggest to strategise and submit PTD application again explaining the situation in more detail.

I also recommend you to speak with a Life Insurance Lawyer.

I hope this answers your question.

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Kind regards
Owais