South Africa — how pre-existing exclusions usually work

The test in this jurisdiction

Most South African group income-protection and lump-sum disability wordings do not exclude every illness you ever had. They exclude disablement that is caused by a condition you knew about, were treated for, or had symptoms of in a short look-back (commonly six months before entry), and — on many group contracts — only if that disablement happens in the first twelve months of cover (NFO CR356).

Retail policies and credit life can be harsher: some exclude a pre-existing condition for the life of the benefit, or use ‘directly or indirectly’. Even then the NFO still asks for proof of the condition in the defined window and a causal link to the claim event (CR403, CR351). Policyholder Protection Rules require reasonable steps to gather information and fair treatment — asserting an old script without investigating post-cover change is the usual fight.

Underwriting path matters. If the insurer asked medical questions and issued cover, a later ‘pre-existing’ decline may really be a non-disclosure argument, which has its own rules. If cover was automatic (fund / union) with no questions, the exclusion clause is doing the underwriting after the fact — read it strictly.

Limbs to check

1. Limb 1 — look-back Did the person know of, receive advice or treatment for, or have symptoms of the claiming condition in the look-back months before cover? Contemporaneous notes, not a later narrative.
2. Limb 2 — disablement window On typical group wording: did disablement occur in the first twelve months after entry? If duties stopped after that window, the exclusion often falls away even if limb 1 is true.
3. Limb 3 — causation Was the disablement caused by that look-back condition, or by a new post-cover event / material deterioration that the clause does not capture? Historic injury ≠ proof (CR403).
4. Onus The insurer must prove the exclusion on a balance of probabilities. Gaps in the look-back file are the insurer’s problem if it could have obtained the notes (CR403).