Durban man in nearly 10-year battle with top insurer over R2.5m claim
Durban - A Durban businessman is adamant that the approximately R2.5 million permanent disability claim he made with a leading insurance company, nearly 10 years ago, was a legitimate one.
Instead of receiving payout for persistent lower back trouble after surgery in June 2011, and numerous other back procedures thereafter, Ravichandren (Reggie) Dhurgasamy claimed Discovery Life have used various methods to frustrate and block his claim.
It included bringing a criminal charge against him that amounted to nothing, investigators allegedly tracking and recording his movements, attempting to solicit a bribe from him, and presenting false information to the office of the Long-term Insurance Ombudsman that deliberated over his disputed claim.
The company has denied the 49-year-old Dhurgasamy’s allegations.
Discovery maintains it always acted with fairness, in the best interests of all their policy holders, and that Dhurgasamy’s claim was repudiated mainly because he did not make full disclosure when he applied for a policy in 2009.
The next chapter in the impasse between Dhurgasamy and Discovery will play out in the Durban High Court on Thursday.
That’s when Discovery’s application to have Dhurgasamy’s claim dismissed will be heard.
The legal route became inevitable for Dhurgasamy in 2017 after the ombudsman’s office, upon receiving various submissions from both parties for more than four years, declared they were unable to make a final determination.
This prompted his legal team to serve summons on Discovery in August 2017, in lieu of his claim.
Discovery defended the matter and raised various “legal faults” in Dhurgasamy’s summons, the last of which was pointed out in August.
Dhurgasamy’s representatives made the required amendments but Discovery was not satisfied and moved for the dismissal application.
When Dhurgasamy applied for a policy with Discovery in 2009, he indicated that he had back surgery after an accident in 2001.
When he filed his claim under the Capital Disability benefit in June 2011, he believed he was entitled to receive accelerated capital disability and accelerated severe illness benefits and other boosters.
Dhurgasamy had trouble with his lower back (right sciatica) and claimed the resulting permanent disability prevented him from working as a manager in a security business.
Discovery repudiated the claim. Their contention was that he received back treatment on two occasions (2006 and 2007) from a general practitioner (GP), who diagnosed his condition to be spondylosis.
Therefore, the consultations were deemed to be non-disclosure of relevant information medical, which impacted the policy he received from Discovery.
Dhurgasamy approached the ombudsman for assistance.
About the GP consults, Dhurgasamy said the 2006 consult was required because he experienced buttock pains after a long drive from Johannesburg to Durban, and, in 2007, he had pain after playing soccer.
The ombudsman viewed the consults as isolated incidents of back pain, were not a “disorder” and Dhurgasamy’s non-disclosure of the consults were not wrongful and ruled in his favour in July 2012.
After making their assessments, Discovery responded by making payments totalling R130 050 and categorised his condition to be temporary in nature (Category C).
Discovery refused to make further payments because Dhurgasamy’s policy had lapsed in April 2012 – he claimed that he was in a dire financial position at the time. In August 2012, Dhurgasamy requested a reassessment of his claim and that it be placed on Category D, which relates to permanent disability and the inability to work.
According to Dhurgasamy, Discovery assigned investigators who followed his movements.
He claimed that the investigators would also follow him into medical facilities where he was treated and chat to staff to check the authenticity of his condition.
On one occasion, they tracked him to the Suncoast Casino and on another to a nightclub, and shot videos without his knowledge.
He claimed that the investigators also attempted to solicit a R200 000 bribe from him by saying they could get his claim approved, but he realised it could be a trap and arranged for police to be present when the supposed money exchange happened, at his daughter’s nightclub in Umhlanga.
Dhurgasamy said the investigators realised the police presence and did not follow through with their plan.
Discovery also opened a fraud charge at the Sandton SAPS, in Johannesburg, on allegations that his tax submissions to SARS were false, but the National Prosecuting Authority found the matter did not warrant prosecution.
Discovery was firm in their belief that Dhurgasamy was not disabled.
This triggered reams of correspondence filed with the Ombudsman from Dhurgasamy, to state his case and it included a comprehensive assessment from a spine and orthopedic surgeon, including his medical history, in 2014. Dhurgasamy also accused Discovery of deliberately stalling and misleading the ombudman’s processes with their cherry-picked evidence submissions.
Unable to clearly determine Dhurgasamy’s entitlement to the claim and not satisfied with the evidence Discovery provided, the ombudsman could not make a final determination.
In providing a response, Discovery Life’s chief executive Riaan van Reenen said claim specialists were assigned to ascertain the veracity of claims, and was confident their investigations were conducted in accordance with the law and in a fair manner.