National Financial Ombud (South Africa) · CR403 · 2024

Pre-existing condition clause — onus and look-back proof

Claim paid after the office put the insurer to proof.

What happened

A long-haul truck driver joined group risk cover on 1 November 2016. Date of disability 1 July 2017: anterolisthesis and spondylosis with left-leg weakness. The insurer declined on a six-month look-back, pointing at a 2003 train accident and a later doctor’s line that he had had chronic lower-back pain ‘since 2003’.

Holding / approach — The insurer must prove, on a balance of probabilities, both that the look-back condition existed in the contractual window and that it caused the disablement. A historic injury and a broad ‘chronic since 2003’ sentence are not enough. First consultation in the file was 8 March 2017; a June 2016 heavy-vehicle medical had given a clean bill of health; the leg weakness the insurer relied on started in 2017, after cover.

What to capture on the file

Ask for contemporaneous notes in the look-back months — not a later summary. Capture fitness-to-drive / occupational-health clearances just before cover. Separate the old injury from the symptoms that actually stopped the job.

What happened

What to capture on the file

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