National Financial Ombud (South Africa) · CR276 · 2009

Partial permanent incapacity — residual other work is not the insured occupation

Provisional ruling: 20% partial permanent incapacity benefit; insurer abided.

What happened

Attorney with severe IBS claimed partial permanent incapacity. He was doing a ‘token’ sheriff role. The insurer stacked technical defences (late submission, non-disclosure, termination) and disputed the merits.

Holding / approach — The sheriff work was not the professional duties he trained for as an attorney, was not full-time, and was only residual income. He could not carry out attorney duties with regularity; a limited, low-stress remnant might remain. Impact was significant but assessed at 20% partial, not a nil claim and not a 50% scaling on the gastroenterologist’s suggestion alone.

What to capture on the file

Name the occupation the policy actually insured. A stripped-down or unrelated job used to stay occupied is evidence of residual function, not proof that own-occupation duties continue. Partial percentages in lump-sum products are a different door from IP residual formulae.

What happened

What to capture on the file

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