National Financial Ombud (South Africa)
· CR259
· 2009
Total under own occupation — employing others to do the labour
Insurer accepted total and permanent incapacity on the occupational definition.
What happened
Back injury. The insured kept the business running only by employing people to do the manual work he used to contribute (about 70% labour). The insurer treated continuation of the business as capacity.
Holding / approach — Keeping a business alive by substituting other people’s labour is not performing the insured occupation. On the policy definition he was totally and permanently incapacitated. (A separate occupation-change notification clause still mattered for prejudice.)
What to capture on the file
If the person ‘still has a company’, list who now does each material duty. Ownership or supervision is not the labour the wording insured unless the occupation was already managerial.
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