Cape Town – Insurance giant Discovery Life has come under fire for refusing to make a payout to a client of 15 years after the Constantia man was involved in a near-death car accident earlier this year.
Brian Daniels was 65 years and four months old at the time of the June 7 crash – the cut-off time for Discovery’s payout was 65 years and one month.
Even after his distraught family escalated the matter, saying that their loyalty to Discovery over 15 years and a policy debit order totalling R700 000 in the last few years could warrant reconsideration, Daniels’ son Troy said the insurer still refused to pay.
After his father was involved in a head-on collision into a tree, he was rushed to a nearby private hospital by medics on the scene.
“After finding out that Discovery didn’t cover the hospital, we, in a rush, sent him to a local state hospital.
"He was in such a critical condition that we chose not to move him again to a Discovery-approved private hospital.
"He stayed at the state hospital for three weeks,” Troy added.
“When my father was discharged, the reality of the accident became more apparent.
"He was unable to walk, had a crushed larynx and terrible muscle loss.
"(Due to) his concussion, he will never mentally be the same again either,” Troy said.
His mother Helen was traumatised and struggles to cope with the impact of the accident on their lives, he said.
“We turned to Discovery after being told that (with) any life-threatening eventuality such as a heart attack, stroke, cancer, etc, my parents would receive their full R14m payout as per their policy.
"One may deem a life-threatening motor vehicle accident such as this life-threatening, especially the after effects. Sadly, our broker came back to us with the news that the cut-off time for said payout was 65 years old.
"My dad was 65 and four months. Hoping that a grey area or a human factor may be seen, our broker went to the head of department. Discovery’s answer was no.
"He is too old. My parents have since cancelled their policy. They have chosen to forego any medical cover,” Troy said.
Daniels is back home and recovering, but the physical, mental and emotional effects have rocked the family, Troy said.
In a letter to their broker indicating the cancellation of any further relations with Discovery, Helen said: “It is with great disappointment that Discovery could not see their way clear in any manner or form to assist Brian in his hour of need, after being a loyal member to Discovery Life, paying for eventualities much like his accident, but rather choosing to take the ‘wait-and-see’ attitude to hear if Brian presents with a heart attack or stroke complication, which could be fatal.
“You did explain that in the likelihood of this happening that there would be no hesitation in an immediate payout, or any other life-threatening illness for that matter, such as cancer, which in my opinion is termed as a traumatic event.
"My argument is that surely in these traumatic events the Discovery payout is obviously given to assist the patient to live and not to die.
"And this is what we were hoping for in Brian`s case, and we all still continue to hope for him to make a recovery and not deteriorate.”
Discovery Life head of claims Sylvia Steyn said Daniels had both Medical AccessCover which ends at the age of 65 and life cover payable in the event of death.
“Unfortunately the injuries he sustained do not fall under any of the conditions covered by Medical AccessCover, such as Stage 4 cancers and heart and lung transplants.
"Each claim is assessed on an individual basis and unfortunately Mr Daniels’s claim doesn’t meet the required criteria,” Steyn said.
Medical AccessCover lapses at specific ages for specific conditions, she said, adding that medical access cover is designed to give clients early access to their life cover while still alive for a range of specified events.
In this case, the medical injuries/conditions sustained following the accident are not covered under the Medical AccessCover.
"Medical Access Cover is available to the principal and spouse on a policy until the end of the month in which they turn 65. He was over the age of 65 when the accident happened,” Steyn said.
“The claims decision does not imply that we do not empathise with the severity of Mr Daniels’s condition and difficulties the family has gone through. However, this exact benefit does not cover the nature of the injuries sustained.”
Discovery life has further indicated:
"There are a number of points we would like to clarify. Firstly, we extend our sympathies to Mr Daniels and his family for the trauma experienced through his car accident.
"Discovery Life always looks for reasons to pay claims and in this instance, confusion appears to have arisen out of Mr Daniel’s application to consider a claim under the Medical AccessCover benefit.
"This is a benefit that Discovery Life automatically includes at no fee for qualifying clients on their policies, which allows them to access a portion of their life cover on certain specified severe illnesses, where a client’s life expectancy is significantly reduced, but they are not considered terminally ill.
"It is only available up until age 65 and is subject to objective medical criteria. Despite the age criteria, we investigated Mr Daniels’ injuries following his accident on request from his family, but his claim was declined because the injuries sustained by Mr Daniels did not meet the criteria of the Medical AccessCover benefit. The reason for the declined payment was not because of Mr Daniels’ age.
"As background, Mr Daniels had a life insurance policy, on which he only had a life cover benefit, which is payable in the event of death.
"This policy was not selected with benefits such as severe illness or disability cover which are specifically designed to assist clients for a broad range of life-changing events.
"Traditionally, life insurance companies only allow clients to receive a payment under their life cover benefit on death or terminal illness. The terminal illness benefit allows you to receive your full sum assured if you are diagnosed with an illness where your life expectancy is less than 12 months.
"Discovery Life’s medical panel, in conjunction with the treating specialist, will confirm the assured life’s life expectancy. Fortunately, Mr Daniels did not die or incur a terminal injury.
"It is also important to explain that Mr Daniels’ experience in being admitted to hospital was not related to his Discovery Life policy.
"Mr Daniels was previously a member of the Discovery Health Medical Scheme but had not paid premiums for a period of time, hence the hospital not recognising him as having medical scheme cover.
"Under the circumstances, access to any private hospital would not be guaranteed, unless the situation was life threatening. It is also important to clarify that the purpose of life insurance is not to provide funding for hospital events and could not be utilised as such."