TPD Case 3
Ms Jeannie (not her real name) made a claim for a total and permanent disability (TPD) benefit as her medical condition, “Schizencephaly with focal epilepsy”, had stopped her from continuing work as a junior accounts officer.
The Insurer found that Ms Jeannie’s condition did not meet the terms of the policy as she could still eat and attend to herself. They claimed that Ms Jeannie’s latest medical assessment revealed that she has full range of movement on all joints with muscle power of grade 4 on all limbs and is able to perform all “Activities of Daily Living”.
Ms Jeannie was unhappy with her insurer’s decision and filed a complaint against them with OFS
Investigation and Findings
The Case Manager scrutinised Ms Jeannie’s policy and noted that the Total and Permanent Disability (TPD) definition is divided into 3 categories as stated below:
"Total and Permanent Disability" means
(I) The disability which is
(a) Total and permanent condition and
(b) such that there is neither at the time disability commences nor at the time thereafter any work, occupation, or profession that the Insured Person can ever be capable of doing or following to earn or obtain any wages, compensation or profits.
(II) The occurrence of any of the following:
(a) The total and irrecoverable loss of sight of both eyes, or
(b) The loss by severance of :
(i) both hands at or above the wrists, or
(ii) both feet at or above the ankles, or
(iii) one hand at or above the wrist and one foot at or above the ankle, or
(iv) loss of sight of one eye and loss of severance of one limb.
(III) The disability must be total and permanent, and such that on the basis of objective medical evidence the minor Insured Person is so helpless, as a result of illness or physical injury, that he/she is, totally and permanently, unable to perform at least 4 out of the 6 activities of Daily Living listed below without the assistance of another person:
(ii) Dressing and undressing
(iii) Getting to and using the toilet
(iv) Transferring from bed to chair and chair to bed
(vi) Eating and drinking
The above additional condition stated in item (III) shall only apply to the Insured Person who is (a) a minor of age below 18 years and must be (b) with no gainful occupation.
From the above definition, the first category applies to insured who are working. The second applies to insureds who suffered losses of the limbs or visions and the third category applies to insureds who are minors (aged 18 years and below) and dependent on others for financial support at the time of the disability(non-working insured). Based on the policy definition above, the Case Manager opined that Ms Jeannie should be assessed under the first category as she was still working at the time of disability. Her ability to perform all “Activity of Daily Living” without limitation should not be used by the Insurer as a reason to reject her claim.
Furthermore, based on the latest medical evidence, Ms Jeannie’s attending physician has clearly stated that she has loss full control of her bodily movement (ataxia) and was unable to speak articulately (dysarthria) and as a result, she is physically and mentally incapacitated which prevented her from continuing employment and earning wages. Her disability remains stagnant with no full recovery expected. Additionally, the Case Manager also noted that Ms Jeannie was admitted in January 2018 with prolonged status epilepticus with physical & cognitive sequelae impairments which are permanent for more than one year.
The Case Manager opined that the attending physician being medically qualified and having the advantage of personally examining Ms Jeannie would be the best person to decide on her disability and whether she will be able to engage in any occupation. Furthermore, the attending physician had confirmed that Ms Jeannie is certified as TPD since March 2019.
Based on the findings, the Insurer reviewed the claim and accordingly made settlement.