CONSUMER WATCH: Truth and lies - the story of a repudiated job injury claim

25 May 2016 - 16:43 By Wendy Knowler

What a shame a shocking case study in the just-released 2015 annual report of the Ombudsman for Long Term Insurance doesn’t name any of the parties involved. The relentless fabrication which resulted in the consumer having his income protection claim rejected make for jaw dropping reading.It’s a “he said‚ she said” of epic proportions.The complainant‚ whom I’ll call Ben‚ for no particular reason‚ claimed on his income protection policy on the basis that he had suffered a permanent‚ disabling back injury a few months after the inception of the policy in 2011.But his insurer declined the claim on the grounds that Ben had failed to disclose a 2008 back injury when he took out the policy.The Long Term Insurance Ombudsman upheld the insurer’s repudiation‚ because the insurer produced a report from an orthopaedic surgeon stating that “the (2008) MRI scan shows disc prolapse”.Ben refuted this‚ insisting that all that had happened was he’d suffered a minor back injury at work in 2008; he saw a general practitioner who prescribed ointment and he was back at work the next day. He’d had no treatment whatsoever for his back before his 2011 injury‚ he insisted.But the insurer had orthopaedic surgeon’s notes reflecting that on July 23‚ 2008‚ Ben was admitted to a particular hospital and the following was noted a week later: “Continue with physio. Book for radiofrequence and MRI Scan – disc prolapse.”The Ombud felt at that point that the complaint would be more appropriately death with by a court of law‚ and dismissed the case.But Ben was not done.He produced what the Ombud calls a “a telling piece of evidence” - a letter from the hospital to which he was allegedly admitted in July 2008‚ stating that no MRI scan could have been performed there because the MRI scanner was only installed at the end of 2012.Lie number one.Undeterred‚ the insurer then produced “information” that Ben had actually undergone the MRI in question at another hospital on July 23 2008.As it turned out‚ that was lie number two.“Something was amiss‚” said the Ombudsman; something of an understatement.The Ombudsman office’s rules allow for a case to be re-opened if new evidence becomes available‚ and thus‚ with the consent of both parties‚ an informal hearing was held at the Ombud’s offices‚ attended by both Ben and representatives of the insurer.There Ben said‚ among other things‚ that he had never been admitted to any hospital for any back problem; said that he had established that the orthopaedic surgeon practices at the second-mentioned hospital in Gauteng‚ but denied ever having set eyes on him; nor had he ever undergone any MRI scan or any operation to his back‚ he said.He went as far as revealing his back at the hearing to prove that he had no operation scar.The said surgeon had apparently completed a medical report stating that he had also seen Ben on October 8‚ 2008 and again on January 14‚ 2009. And there was also an account from the second mentioned hospital reflecting a debit for January 14‚ 2009.More lies.According to the Ombudsman‚ Ben produced “a formidable body of evidence”‚ including a number of dated photographs‚ “which established as an incontrovertible fact that from about September 2008 until about December 2009 he lived in the eastern Cape”.“In the light of this evidence‚ the inescapable conclusion was that it was just about impossible that this doctor could have seen the complainant on 8 October 2008 or on 14 January 2009.“The virtual impossibility that the doctor could have treated the complainant (at those times) raised serious misgivings about the insurer’s case… “In the light of the apparent unreliability of the medical information which had been provided to the insurer‚ it did not need to call any witness and at the conclusion of the hearing the insurer accepted the validity of the claim which it undertook to assess.”So the truth - and Ben along with it - won in the end‚ but only because Ben stuck to his guns.Had he not had the time or the energy to pursue the matter‚ the completely false medical records would have left him “guilty” of the non-disclosure of a previous‚ serious back injury.The matter has been reported to the Health Professions Council of South Africa...

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