Exclusion - Accidental vs Illness Case 1

Background

The claimant’s death claim was repudiated by the Takaful Operator as the Participant’s death was not solely and directly due to accidental means but due to Myocardial Infarct, an illness and therefore does not fall under the Certificate coverage that provides benefits in the event of accidental death or accidental bodily injury.

 

Investigation and Findings

The Takaful Operator’s decision was based on the terms and conditions of the Certificate which states as follows:

1. Accidental death- The sum covered for death benefit shall be payable if the person(s) covered dies due to accidental causes other than the excluded risks as stated in thisdocument,…”
2. General Exclusions- We do not cover any loss or injury directly or indirectly caused by the following:
   5.2 Hernia, illness, disease... pre-existing physical problem or condition and its direct implications;”

 

OFS’s View

Based on the supporting documents submitted, the Case Manager noted the following:

1. The post mortem report from hospital stated that the cause of death was ‘myocardial infarction’;
2. Based on the medical website, ‘myocardial infarction’ is the medical name for heart attack. It occurs when blood flow decreases or stops to a part of the heart, causing damage to the heart muscle;
3. The post mortem report indicated that there were bruises measured 2cm x 3cm at the right side of the Participant’s head. However, it was not fatal enough to contribute to the Participant’s death;
4. The ‘post mortem’ or an ‘autopsy’ is an examination of a body after death to determine the cause of death. Post-mortem is carried out by pathologist. Thus, their finding would be considered vital evidence to know the cause of death.
5. There was no evidence or proof provided to indicate that the sole cause of Participant’s death was due to fall. The Participant’s condition was not accidental as it was not solely and directly caused by an accident.

 

Resolution

Recommendation Issued: Based on the facts and circumstances of the case, the Case Manager was of the view that the Takaful Operator had repudiated the claim in accordance with the terms and conditions of the Certificate.Thus, the Case Manager had affirmed the Takaful Operator’s decision to repudiate the claim.