Accident Claim Temporary Total Disability Claim Case2

Background

Encik Kamal (not his real name) had twisted his right ankle on 13/1/2018 while playing football. He sought treatment at a clinic a day after the accident and was told by the physician to continue with the medication and see him in two weeks’ time if the pain persists. Unfortunately, his injury worsened, and he sought treatment at a hospital on 3/2/2018. An x-ray was done, and the result revealed the injury was “Jones Fracture”. Following the advice of the physician at the hospital, Encik Kamal underwent a surgery on 5/2/2018. Encik Kamal filed a total temporary disability claim with the Insurer. Unfortunately, the Insurer said claim was not covered because he had only sought treatment on 3/2/2018, which was not immediately from the accident date as required under the policy terms and conditions.

 

Investigation and Findings

The Case Manager investigated into the claim and perused the policy term. Encik Kamal policy carries the following clauses:

“TEMPORARY TOTAL DISABILITY means disability arising from accidental injury, which entirely prevents the Insured from attending to his business, profession or occupation from the date of accident.

…. Insured’s Injury has resulted in Temporary Total Disability that prevents him from performing any duty pertaining to his occupation from the date of accident subject to:

- Temporary Total Disability must be at least seven (7) continuous days.

- The Benefit payable is only for the period of continuous disability excluding any period of disability following a break.”

 

The Case Manager had also reviewed the medical reports from the clinic as well as the hospital to determine the treatment Encik Kamal had received.

The Case Manager opined that if Encik Kamal received proper consultation and was asked to do an x ray on 14/1/2018 itself, the fracture would have been diagnosed earlier and he would have sought treatment at hospital on the same day. Although the policy terms specifically stated that the treatment must be done immediately from the date of accident, medical evidence shows that Encik Kamal’s delay was not deliberate because as a layperson, he had merely followed the physician’s advice and sought treatment at the hospital after the pain persisted.

 

Settlement

Taking into consideration the reason for Encik Kamal’s delay in receiving treatment, the Insurer agreed to settle the claim.