National Financial Ombud (South Africa) · CR72 · 2005

Total disability — part-time capacity is not automatically ‘not total’

Insurer made an ex gratia offer of half the claim after ambiguous handling.

What happened

Clerical occupation. Severe sciatica. An occupational therapist said that even with pain-management and ergonomic changes he could probably only work part-time. The insurer treated leftover capacity as defeating total disability.

Holding / approach — The useful question is whether, in normal times and most places, an employer would consider the person capable of playing a worthwhile part in the business — performing the substantial and material clerical duties with reasonable regularity and continuity — and would pay more than a nominal gain. Part-time leftovers are not, by themselves, the occupation.

What to capture on the file

If the insurer points at two hours of email, ask whether that is a worthwhile, regular performance of material duties for real pay. Capture unreliability: leaving early, unpredictable pain, days that cannot be rostered.

What happened

What to capture on the file

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