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• 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.