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Wiki
A live index of what the Library already holds — language, glossary, traps, gaps, workflow, clinical atlas, Compass programmes, news — plus names that are referenced on the site but do not yet have their own article. It rebuilds from those sources; new terms appear here when they are added.
469 defined · 15 need definition · 484 total · showing 9
All A B C D E F G H I J L M N O P Q R S T U V W X Y Z
All kinds Claim workflow (9) Clinical atlas — condition (106) Clinical atlas — medicine (87) Confusion pair (11) Disability / incapacity (33) Dispute hub (2) Evidence gap (6) Glossary (27) Language map (20) Life insurer (85) Module (8) Needs definition (15) News (3) Ombud guidance (4) Ombud precedent (9) Policy scan (12) Policy trap (11) Rejection ground (12) Social Security Compass (36)
A
- AFCA Approach — ICA s 47 — Section 47: awareness of a pre-existing condition, not the diagnosis label Ombud precedent If, before the contract, the consumer was not aware of the condition and a reasonable person in those circumstances could not be expected to have been aware of it, s 47 stops the exclusion. Awareness sits between a stray symptom and a stamped diagnosis: consultations, investigations, and contemporaneous GP notes carry the weight. Later recollection that ‘it was nothing’ is often discounted. Awareness of the condition at any time before entry defeats s 47, even if the person reasonably believed they no longer had it.
- AFCA Approach — life insurance non-disclosure — Non-disclosure remedies are not a substitute pre-existing clause Ombud precedent A s 29(6) variation must put the insurer in the position a reasonable and prudent insurer would have been in at entry. AFCA may narrow or strip a retrospective exclusion that other prudent insurers would not have applied. Declining the claim and varying the contract are two decisions; each needs its own proof. An exclusion that does not cover the claimed condition does not save a bad variation.
- AFCA published IP determinations — Total and partial are separate benefits — AFCA applies the PDS as written Ombud precedent AFCA does not grade medical severity as ‘total’ or ‘partial’. It asks which definition the person met in each month: hours actually worked, important income-producing duties, and earnings against pre-disability income. Working more than the hours threshold usually takes the file out of total and into partial — if the earnings drop and duty test are also met. Not working, but still able to do the important duties, fails total. A graded return is often residual, not recovery and not a failed total claim. Where the PDS deems a ≤10-hour week to be a 100% loss, AFCA applies that deeming.
C
- CR259 — Total under own occupation — employing others to do the labour Ombud precedent Keeping a business alive by substituting other people’s labour is not performing the insured occupation. On the policy definition he was totally and permanently incapacitated. (A separate occupation-change notification clause still mattered for prejudice.)
- CR276 — Partial permanent incapacity — residual other work is not the insured occupation Ombud precedent The sheriff work was not the professional duties he trained for as an attorney, was not full-time, and was only residual income. He could not carry out attorney duties with regularity; a limited, low-stress remnant might remain. Impact was significant but assessed at 20% partial, not a nil claim and not a 50% scaling on the gastroenterologist’s suggestion alone.
- CR351 — Pre-existing exclusion — proximate cause, not every historic diagnosis Ombud precedent 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.
- CR356 — Two-limb pre-existing exclusion — look-back and first twelve months Ombud precedent 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.
- CR403 — Pre-existing condition clause — onus and look-back proof Ombud precedent 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.
- CR72 — Total disability — part-time capacity is not automatically ‘not total’ Ombud precedent 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.