When Bert got injured in an accident, he couldn't work as an electrician anymore. He came to us when his insurer stopped his benefits.
Bert trained and work as an electrician. He took out an income protection policy, which would cover him for up to 24 months, if he couldn't do his job because of an accident or illness.
According to his policy, this benefit would stop after 24 months unless he medically couldn't do any job he was suited to.
Bert was then involved in a road traffic accident, suffering severe back, neck and arm pain. A consultant orthopaedic surgeon also identified that Bert had a degenerative condition.
He made a successful claim to his insurer and his benefit continued after the initial 24-month period. But a year later, Bert's insurer arranged for a consultant neurosurgeon to examine him. The consultant said that Bert might be able to do a desk-based job.
The insurance company also arranged for an investigator to carry out some video surveillance. It showed Bert bending, lifting, crouching and driving with no obvious restriction. When his insurer brought this evidence to Bert, he produced his doctor's report which confirmed his ability to do some tasks.
But Bert explained to them that any activity was done at risk to his health. He also explained that undertaking a job could aggravate his condition.
What we said
We looked at all the facts and evidence from both sides. We accepted that Bert's condition had continued to deteriorate and that he was now incapable of any work. But we had to decide whether he had met the policy definition of 'total disability' when his benefits stopped.
Based on the medical evidence that Bert gave us from that time, we felt that he might have been able to do some 'light' duties in a job.
So he could keep receiving benefits after the first 24 months, he needed to meet the policy definition of 'unable to perform any occupation'.
We decided he didn't meet these criteria, so concluded that the firm had been right to withdraw his benefits, and didn't uphold Bert's complaint. But Bert's insurer agreed to refund Bert's premium as a gesture of goodwill.