Total and Permanent Disability Claim: Definition of TPD not fulfilled Case 1
The Insured was diagnosed with Parkinson disease. The Insured’s claim for Total and Permanent Disability (TPD) benefit was rejected by the Insurer on the ground that his condition does not fulfill the policy definition of TPD.
The relevant policy definition states as follows:-
“Total and Permanent Disability (TPD)
For a Life Assured who is Gainfully Employed
A disability which is total and permanent and persists continuously for a period of at least six(6) months, and which wholly prevents the Life Assured from ever performing his occupation or other occupation for which he is reasonably fitted by reason of training, education or experience.
To be considered permanent, the disability should persist continuously for a period of at least six(6) months.
The disability shall nevertheless be understood to have begun on the first days that such disability occurred.”
The Insurer rejected the claim based on the medical assessment made by the Insured’s attending doctor who stated that disability suffered by the Insured does not prevent him from returning to work or to perform any type of occupation as long as it does not involve strenuous physical activity involving operation of machinery. The attending doctor further confirmed that the Insured still have full power of both upper and lower limbs and that his condition has improved. The attending doctor also stated that the Insured illness is at stage II and therefore is considered as a moderate form of Parkinson.
Investigation and Findings
Based on the latest medical report from another attending doctor dated 17 May 2017, the Case Manager observed that:
a). the Insured’s Parkison disease is a progressive disease with no prospect of improving.The Insured is subject to constant drug adjustments depending on his clinical condition.
b). although the Insured is ambulatory, both of his hands’ fine manipulation skills are impaired.
c). the treating doctor also confirmed that the Insured’s disability prevented him from returning to work and attending to his/her existing occupation immediately as well as any form of occupation. This is due to the Insured having difficulty in performing voluntary movements (Dyskinesia) as well as problem with motor coordination besides having to deal with motor complication. The treating doctor further stated that the Insured’s disability is permanent.
The Case Manager noted that the treating doctor did suggest that the Insured probably can try to do a desk job. However, the Case Manager was of the view that a desk job requires the use of both hands, and the Insured’s fine motor manipulation skills are already impaired.
Based on the above findings, the Case Manager was of the view that it is unlikely the Insured at the age of 50, without any substantial training on other job skills except being in the hotel industry under the food and beverages section since 1990 until his resignation in 2016 would be able to secure a substitute occupation for which he is qualified by age, experience, education or training.
Based on the above observation, the Case Manager requested the Insurer to review the claim.
The Insurer agreed to review and settled the claim.