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Long -term Ombudsman

This case, from the office of Judge Brian Galgut, the Ombudsman for Long-Term Insurance, illustrates how significant a relatively small amount can be to a family with financial difficulties.

The complainant’s husband purchased a health policy/hospital plan in 1992. The policy provided for the payment of a specified rand amount when the life insured is hospitalised or undergoes a listed procedure. The complainant’s daughter was hospitalised to remove her thyroid because it was cancerous. After the operation the complainant phoned the insurer’s call-centre to enquire whether the policy would cover radioactive treatment which was required to eradicate any remaining cancerous cells. The recording of the call revealed what the advice of the call-centre consultant had been:

Consultant: The treatment is to do with cancer?

Complainant: Yes.

Consultant: Forcancer treatments all accounts are covered on that policy.

Complainant: They all covered?

Consultant: Yes. So what we need is copies of all accounts to do with cancer treatment including the doctor’s consultations, so that we can work out the benefit for her. Even when she goes for future treatments you will submit just accounts without the claim form. The claim form that you are about to submit right now must be completed by the main member, Mr R, and the attending doctor.

The treatment was administered but when the account for the treatment was submitted the insurer declined to pay all of the costs. In terms of the policy, the stated benefit amount was paid, only R8 727 of the amount claimed.

The insurer pointed out that the policy was a ‘topup’ product covering the shortfall not paid by medical aid. The complainant had no medical aid and had been under the impression that the policy was a substitute for it.

The office upheld the insurer’s defence that the policy did not cover the full costs of the treatment. It was our view, however, that the call-centre consultant had brought the claimant under the wrong impression that the cost of the treatment would be paid. When the office raised this with the insurer, it agreed to pay an additional R8 600 which covered most of the shortfall. The complainant was pleased to accept the offer.

She wrote to the office as follows:

Firstly thank you for all your help. If I understand correctly, they will pay us a further R8600,00 which will be in final settlement of the claim. We now know that our hospital plan was not what we were led to believe.

This is going to help take a load off my daughter’s shoulders. The other night at supper she turned to her dad and said that she knew what financial stress we were under because of her medical bills so she said she didn’t want a present for Christmas this year! Even through all that she has been through she has managed to stay in the top 10 of her grade at school and has now been chosen to be head girl for next year!

Thanks again for all your help. I know it is sometimes easy to forget that there are real people behind these claims so I just wanted to let you know how you have positively affected someone’s life. I cannot say thank-you enough.







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