Ombud sides with policy holder in his fight with Clientele Life
The long-term insurance ombudsman overrides a clause about waiting periods, forcing the insurer to pay for eight days of hospitalisation
The ombudsman for long-term insurance has ordered Clientele Life to compensate a policy holder whose claim for unforeseen hospitalisation costs was rejected. The daily cash benefit amount, according to the insurance plan at the time, was R2‚000.
The office of the ombudsman said the complainant’s policy commenced on April 1 2015‚ with the mandatory six-month waiting period ending on October 1 of the same year. "The complainant was admitted to a Margate hospital as an emergency patient on September 10 2015. He was subsequently transferred to another hospital on October 5 2015‚ and stayed a total of 26 days in hospital. In terms of the policy conditions‚ this was regarded as one continuous period in hospital‚" the office said.
Clientele Life declined the claim on the basis that the man was hospitalised during the waiting period. According to the policy: "No claims as a consequence of illness will be considered during the waiting period."
But the ombudsman pointed out that there was no requirement in the definition of the waiting period that claims would only be considered if the date of admission to hospital was after the expiry date of the waiting period. "As the complainant was discharged from hospital on October 8 2015‚ we advised Clientele Life that we believed it should pay for eight days of hospitalisation‚" ombudsman Judge Ron McLaren said.
Clientele Life maintained that the claim arose during the waiting period‚ however, the ombudsman made a final determination ordering that the complainant be paid for eight days of his hospital stay.
Clientele Life was approached for comment‚ but had not responded by the time of writing.