Why a medical report isn't enough for disability insurance claims

A MEDICAL report does not automatically qualify an employee for disability insurance, according to the National Financial Ombud Scheme of South Africa (NFO).

- DIEKETSENG MALEKE

It said, while medical reports serve as key evidence, the employer's medical boarding policy may differ significantly from the criteria used by insurers to determine eligibility for disability benefits.

The (NFO) describes itself as a single, one-stop, dispute resolution service made up of four former longstanding industry ombud schemes: the Ombudsman for Short-Term Insurance, the Ombudsman for Long-term Insurance; the Credit Ombud and Ombudsman for Banking Services. Services are provided free of charge. According to the NFO, medical evidence forms part of a broader application process that assesses the nature and extent of the disability, as well as the individual's ability to perform their duties, whether in their current occupation or an alternative role.

The NFO says it regularly receives complaints from employees who have been dismissed due to incapacity or medically boarded by their employer, but later find their disability claims denied.

"The employee and the employer operate under the assumption that if the employer's doctor has declared the employee disabled for work, the insurer would pay his disability benefit. This is not correct. “The employer's boarding or incapacity process and an application for disability benefits from an insurer in terms of the policy contract are two distinct processes," says Denise Gabriels, lead ombud of the Life Insurance Division at the NFO.