Den­tist ‘en­ti­tled to his dis­abil­ity ben­e­fit’

Weekend Argus (Saturday Edition) - - GOOD WEEKEND - BRUCE CAMERON

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”.

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