Dentist ‘entitled to his disability benefit’
The Professional Provident Society Insurance Company (PPS), which provides financial products to professionals, wanted a 59-year-old dentist, who suffers from serious heart ailments, blindness in one eye, hypertension and gout, to carry on working.
But Judge Brian Galgut, the Ombudsman for Long-term Insurance, intervened and ordered that the dentist be allowed to retire.
When the dentist, who was not named, stopped practising because of ill-health, he submitted a claim to PPS, which paid him a sickness benefit for two years.
After two years, PPS considered him for a partial permanent incapacity benefit but assessed him to be 20-percent “partially permanently incapacitated”. This means that PPS considered the dentist to “permanently but not totally unable to carry out his own profession, as well as any other profession that could be carried out by persons with similar or comparable qualifications”. In terms of PPS’s policy, the benefit is paid out as either 20 percent or 60 percent of the insured sum.
The dentist wanted a 60-percent pay-out, but when this was rejected, he took the issue to the ombudsman. PPS claimed the dentist:
◆ Was still practising his profession on a partial basis, because he was developing a managed healthcare programme for the African continent;
◆ Could still practise as a clinical dentist, albeit not on a fullday basis; and
◆ Had not been on maximum medical intervention, as required in terms of the policy. Galgut found that:
◆ The dentist’s work on the healthcare programme was done voluntarily as part of a project to make affordable health care available for people across Africa. Galgut did not regard this “as practising his profession as a dentist”.
◆ Medical evidence showed that the dentist was not fit to continue working as a dentist.
◆ There was no requirement in the policy that the dentist, who was on medical treatment, should undergo a heart bypass operation as suggested by PPS.
PPS rejected Galgut’s initial determination, but in a review of the determination the judge confirmed that the dentist be paid a 60-percent benefit, even though he found that the dentist could still pursue non-clinical work using his professional qualifications.
Galgut said his office “did not find PPS’s arguments convincing”.