Life insurer rejects R2.4m policy payout for blood sugar non-disclosure
News / 17 November 2018, 12:30pm / Tanya Waterworth
Durban - Shallcross resident Nathan Ganas, 42, was killed in a hail of bullets trying to protect his wife, Denise, during a hijacking in the driveway of their Shallcross home last March - and she is now fighting to get a R2.4 million life insurance payout which has been declined by the insurer on the grounds Nathan had high blood sugar levels.
The couple’s 10-year-old daughter, Carmen, now 12, was also injured when bullets ripped through the front of the house during the attack.
The insurer, Momentum, said the claim had been declined because of non-disclosure by Nathan regarding being diagnosed with raised blood sugar levels which may have occurred before he completed his application for the policy in 2014.
Momentum have also asked Denise to repay R50000, which was an instant cash benefit from the policy and which the family used to pay for Nathan’s funeral.
Denise said she was shocked by the rejection: “The post mortem report states that he (Nathan) had died of gunshot wounds and not diabetes.”
With regard to non-disclosure of raised blood sugar levels suffered by her husband, she said as far as she was aware, her husband was never on chronic diabetes medication before the application for the policy, for which he was required only to undergo an HIV test.
“I feel that a grave injustice has been done to my kids and myself in our time of bereavement. My children always used to wait for their dad at the door and they so miss all his hugs.
“My daughter says how sad she feels when she sees other kids with their dads. She asked ‘who is going to have the first dance with me’ at her sweet 16 (birthday). I have to try not to cry. Due to my financial situation, I may have to rethink my living arrangements,” she said this week.
Momentum said Nathan Ganas had failed to provide all relevant information regarding his health.
That the cause of his death (being shot) was completely unrelated to a pre-existing condition (raised blood sugar levels), the insurer said, was “irrelevant, since he had an obligation to provide all relevant medical information to Momentum in the new business application process for the risk to be properly underwritten”. It said this entitled the insurer to reject the claim and to deal with the policy as if the non-disclosed information had in fact been disclosed.
“In this instance, if he (Nathan) had shared the relevant information when it was required, the underwriting decision would have been not to issue the cover and no claim would have existed,” said Momentum.
In some countries, life insurance claims are settled if the cause of death is unrelated to a non-disclosure breach, but not in South Africa.
After Momentum’s rejection, Denise approached the ombudsman for long term insurance, who found in the insurer’s favour, saying they had carried out a comprehensive investigation, including appointing an independent re-insurer to examine the case.
Momentum described Nathan as being on diabetic treatment and suffering from hypertension and the re-insurer found “from the evidence, I am unconvinced that it can be shown beyond reasonable doubt that the deceased was aware he was diabetic at the time of the application. I am convinced however, that the deceased was aware of raised blood glucose tests”.
This finding, according to the re-insurer, was based on five tests over a three-year period prior to the application.
The ombudsman asked the insurers if they would consider applying the Didcott Principle, which is where an insurer may have been misled but would have still entered into a contract on different terms.
But Momentum refused to do so, reiterating, “the principle unfortunately does not apply as Momentum would not have issued the cover, not even with different terms”.
With November being Diabetes Month, the case puts the spotlight on whether those with diabetes or raised blood sugar levels can access life insurance.
Momentum said results of “the blood tests which came to light during the claims process were extremely abnormal which would have meant that we would not have offered any life cover”, but Denise asked if the tests were “extremely abnormal” (prior to the application), why her husband had not been put on chronic medication by their family doctor.
The doctor had not responded to questions at the time of going to press.
Momentum said they would provide cover to clients whose diabetes is controlled within acceptable limits, who are treatment compliant and who do not have any diabetic complications or additional risk factors.