Rustenburg - The High Court in Johannesburg has ordered insurance company, Discovery, to pay over R25 million to a client after it was found to have been plainly unreasonable to reject his claim.
The client identified as PR, challenged the repudiation of his claim on an insurance policy he held with Discovery.
PR who worked as a stockbroker, claimed that at some point between December 28 in 2014 and November 30 in 2015, he had become totally and permanently unable to carry on as a stockbroker.
During that time, he suffered a string of deeply traumatic events that had left him with a combination of post-traumatic stress disorder and unspecified bipolar mood disorder.
He said that, despite psychotherapy, occupational therapy and an extensive range of drug treatments, he would never recover to the extent necessary to work as a stockbroker.
Discovery rejected PR’s claim on the basis that his insurance cover expired on November 30 in 2015, and that there was no evidence that he had become totally and permanently unable to perform as a stockbroker by that date.
According to the judgment handed down on Friday, PR was, prior to the onset of his condition, a very successful stockbroker. His job was high-pressure and high stakes. It also required, like all jobs that involve a degree of deal-making, an agile set of social skills.
"The insurance policy he took out with Discovery is itself evidence of his success. The pay-out due in the event of permanent incapacity was over R25 million. The monthly premium due on the policy was in the region of R20 000. These very large sums bespeak a highly lucrative occupation,“ Judge J Wilson said.
"PR’s job was concomitantly demanding. Both Dr Panieri-Peter, PR’s treating psychiatrist, and Ms Abu-Haj, his occupational therapist, gave unchallenged evidence that PR’s work as a stockbroker required a resilient personality and fine judgment. PR’s work involved the investment of his clients’ funds, and the skilful purchase and sale of financial assets in a manner that would maximise the return on those funds," the judge said.
He was able to purchase a villa in Mauritius. On December 28, 2014, PR was on holiday at the villa with his girlfriend, with whom he was in a long-term and loving relationship, his girlfriend drowned in a swimming pool at the resort of which PR’s villa was a part.
He found his girlfriend floating in the swimming pool. He tried to resuscitate her, but without success.
He was arrested in Mauritius on suspicion of murdering his girlfriend, on January 2 in 2015. He was detained pending trial, and on the same day, he appears to have suffered some sort of breakdown.
He was admitted to the secure ward of a local hospital, and stayed there for four days. On January 8, he was seen by Dr Banymandhub, a Mauritian state psychiatrist.
PR was apparently in a state of psychological distress. Banymandhub saw PR again on February 4 and noted evidence of depressive illness.
By March 31, PR had lost 20kg, and, according to Banymandhub’s notes, he looked mentally and physically exhausted.
He was eventually acquitted of his girlfriend’s murder and he returned to South Africa in March 2016. He was hospitalised in Pietermaritzburg, where he was diagnosed with post-traumatic stress disorder and major depression.
PR was admitted to Kenilworth Hospital in Cape Town on August 28 in 2017 for several weeks. He received psychotherapy, group therapy and various pharmacological treatments.
During the course of his treatment, doctors found out that he suffers from intrusive, recurrent and involuntary memories, and dissociative reactions. He was angry and occasionally self-destructive.
Judge Wilson said PR’s incapacity could not have been diagnosed as permanent until an appropriate course of care and treatment had been administered.
"In this case, the kind of treatment required – in the form of drugs, in the form of psychotherapy, and in the form of occupational therapy – can take months or years to perfect and to implement. In order to assess whether PR’s condition was permanent, Discovery had to have regard to evidence generated well after his policy expired.
"In closing the door to that evidence when it repudiated PR’s claim, Discovery was plainly unreasonable. Had it conducted itself reasonably, it would have become aware, by no later than 1 May 2019, that PR’s incapacity had become permanent, and it would have been bound to pay out on the policy by that date," Wilson said.
The judge ordered Discovery to pay PR the sum of R25 086 456.94. Interest would be payable on that amount from May 1, 2019, being that date on which a reasonable insurer would have been satisfied that PR’s incapacity had become permanent.
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