This matter highlights the importance of a comprehensive evaluation of medical evidence in disability claims, particularly on psychiatric grounds. Insurers must accurately interpret policy definitions and consider the full context of an individual’s condition and job demands. The involvement of the National Financial Ombud Scheme ensured a fair reassessment, leading to the rightful approval of the claim.
We examine a case about a disability claim by a general manager at a car dealership, who’s claim for disability benefits was based on psychiatric grounds that was repeatedly declined by his insurer. The key issues involved the insurer not giving sufficient weight to the available evidence and misinterpreting the policy’s requirements by focusing on the chronicity of the condition, which was not necessary under the policy’s definition of disability.
The complainant served as a general manager, responsible for financial returns, staff management, and branding, with significant cognitive demands. His work split involved 60-70% administrative tasks and interactions with staff and customers.
He was diagnosed with diabetes, hypertension, and hypercholesterolaemia in 2002, he experienced fatigue due to poorly controlled blood glucose in 2006. In 2011 he was diagnosed with stress and anxiety and started medication. Stress at work exacerbated his diabetes management issues.
His employer submitted a disability claim in May 2011, citing inability to handle stress and responsibility, forgetfulness, and underperformance. The insurer declined the claim, citing manageable hypoglycaemia and lack of objective disability evidence.
A second claim included a physician’s recommendation to see a psychiatrist and a psychiatrist’s diagnosis of generalized anxiety disorder and major depression, indicating cognitive impairment and a poor prognosis. The insurer declined again, attributing the symptoms to workplace changes and an employer-employee issue.
A third claim included an occupational therapist’s report, which highlighted significant cognitive and emotional impairments. The insurer again declined, citing controlled hypertension and diabetes, lack of psychological consultation, and insufficient evidence of cognitive impairment.
The complainant filed a complaint with the Ombud. The policy required total incapacity to engage in his occupation for the first 24 months after a three-month waiting period. The complainant’s occupation had high cognitive demands, which he was failing to meet despite employer accommodations. Transferring to a smaller dealership increased his stress due to longer travel.
The insurer emphasized controlled medical conditions and insufficient objective evidence, neglecting the impact of job stress on the complainant’s health. The diabetes educator confirmed the complainant’s conscientious efforts to manage his condition, hindered by work stress.
The insurer disregarded the psychiatrist’s opinion on late-onset depression, particularly given the complainant’s age (62).
The insurer misinterpreted the policy, it did not require permanence or chronicity of the condition, only total incapacity to perform his occupation.
The psychiatrist’s opinion on the negative impact of depression and anxiety on cognitive function was deemed sufficient. If the insurer questioned this, it should have arranged further neuropsychological testing at its own cost. The complainant continued treatment with his psychiatrist for ten months, consistently certified as unfit to work. The lack of psychological consultation was not detrimental since he was under regular psychiatric care.
The insurer the proposed, and the complainant accepted, an independent psychiatric evaluation. The independent psychiatrist confirmed the diagnosis and noted sustained symptoms and poor prognosis.
Following the independent report, the insurer admitted the claim and began paying the monthly income benefit.
At A de Bruyn Attorneys, we understand the complexities and challenges involved in insurance claims, particularly those related to disability on psychiatric grounds. If you find yourself facing similar difficulties with your insurer, we are here to assist. Our dedicated team will work diligently providing the support and guidance necessary to secure the benefits you are entitled to. Trust A de Bruyn Attorneys to help you through the insurance claim process with professionalism and care.