National Financial Ombud (South Africa) · CR351 · 2014

Pre-existing exclusion — proximate cause, not every historic diagnosis

Office distinguished the pre-existing cardiac history from later cancer as the cause of death.

What happened

Credit life. Pre-existing cardiac history. The insured later developed cancer diagnosed after cover. The insurer argued the pre-existing conditions directly or indirectly caused death.

Holding / approach — The exclusion turns on whether the pre-existing condition caused the claim event, not on whether any old diagnosis exists. Medical evidence at cancer diagnosis recorded no cardiac involvement. Historic disease in the background is not automatically ‘directly or indirectly’ the cause.

What to capture on the file

When the file has two conditions, build a causation map: what stopped work (or caused death), when, and which treating notes say so. Do not let a disclosed or recorded history swallow a new post-cover event.

What happened

What to capture on the file

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