Case 3: Eyes related illness - Failure to fulfil policy definition of TPD

Background

The assured’s Total and Permanent Disability (TPD) claim was rejected by the insurer on the ground that his medical condition does not fulfil the policy definition of TPD.

The assured was diagnosed with Eye Retinitis Pigmentosa on both eyes and Bilateral Eyes High Myopia since 1 February 2016 which resulted in his left eye vision to be blurred.

The relevant policy definition states the following:-

“Total and Permanent Disability (TPD)

(b) For working Life Assured

“The Life Assured after attaining the age of 21 years but before the age of 65 years, can ever sufficiently do or follow any work, occupation or profession to earn or obtain any wages, compensation or profit, provided that such disability must last for not less than six months in durations.”

The insurer rejected the claim based on the medical assessment made by the assured’s attending doctor who stated that the disability suffered by the assured does not prevent him from performing all the daily living activities independently and he should be able to perform his current job with limited outcomes.

The assured was not satisfied with the Insurer’s decision. He contended that he can no longer see properly as his eyesight is declining and has to quit his job as architect/designer/consultant engineer due to his medical condition.

Investigation and Findings

Based on the latest medical report from another attending doctor dated 17.10.2017, the Case Manager noted that:

  1. The assured’s illness is a chronic degenerative progressive disorder. It is an incurable illness with no prospect of improving where patient could ultimately become blind.
  1. Although the assured is ambulatory with daily living activities at 85% capacity and with full motor power of limbs, the disability caused by the illness will prevent him from returning to his current occupation or any other occupation.
  1. The assured’s current occupation as an Architect/Designer/Consultant Engineer, is to draw out plans and design. The illness will cause him to have poor vision that will make drawing, designing and writing difficult. His ability to move around outside his home will be difficult too due to unfamiliarity of its surrounding.

Based on the above findings, the Case Manager was of the view that it is unlikely the assured without any substantial training on other job skills would be able to secure other jobs for which he is qualified by experience, education or training.

Based on the above assessment, the Case Manager was of the view that the complainant’s claim warrants a review.

Settlement

The Insurer agreed to review and had settled the claim