National Financial Ombud (South Africa) · CR356 · 2014

Two-limb pre-existing exclusion — look-back and first twelve months

Insurer accepted the office’s reading and paid.

What happened

Group disability income. Entry 1 February 2012. Cognitive and balance symptoms were already being investigated in the six months before entry. He was advised to stop work on 4 February 2013 and diagnosed with senile dementia on 20 February 2013 — just after the first twelve months of cover.

Holding / approach — Typical South African group wording is conjunctive. The insurer needed (a) knowledge, diagnosis, treatment or symptoms of the claiming condition in the six months before entry, AND (b) disablement in the first twelve months after entry. Limb (a) was met; limb (b) was not. Symptoms in the look-back do not keep the exclusion alive once disablement falls outside the first year.

What to capture on the file

Read the clause as two clocks, not one story. Date of disablement is the second clock — often last day able to perform duties, not first symptom and not the diagnosis date. A diagnosis after month twelve can still describe a disablement that started earlier; pin the duty-stop date.

What happened

What to capture on the file

Language map