Total and Permanent Disability Claim: Definition of TPD not fulfilled Case 2

Background

The insured who was involved in a motor vehicle accident on 25 August 2015 sustained an ‘Open fracture proximal left tibia and fibula with neurovascular injury’ and subsequently he had a left above knee amputation.

The insured’s claim for Total and Permanent Disability benefit was repudiated on the ground that his medical condition does not fulfil the definition of Total and Permanent Disability of the policy.

 

Investigation and Findings

The insurer’s decision was based on a medical report dated 28/10/2016 wherein it was reported that the Insured had sustained 50% of permanent disabilities for left above knee amputation due to the alleged motor vehicle accident on 25/08/2015; and the Insured was able to perform more than 3 Activities of Daily Living such as Continence, Dressing, Bathing/Washing and Eating.

The relevant policy definition states as follows:-

“Total Disablement

Shall mean physical disablement as a result of Injury and commencing within three hundred and sixty-five (365) days from the Accident date, a Certificate Holder is totally, continuously and permanently disable and prevented from performing three (3) or more Activities of Daily Living as herein defined which would normally be carried out by him/her in his/her daily life had such disablement not occur.

 

Activities of Daily Living

Definitions attributed to the following words in the Insurance coverage are:

(a) Transfer:Getting in and out of a chair without requiring physical assistance.

(b) Mobility:The ability to move from room to room without requiring any physical

                   assistance

(c) Continence:The ability to voluntarily control bowel and bladder functions such as to maintain personal hygiene.

(d) Dressing:Putting on and taking off all necessary items of clothing without requiring assistance from another person.

(e) Bathing/Washing:The ability to take a bath or shower (including getting in or out of the bath or shower) or wash by any other means.

(f) Eating:All efforts to eat food after it is prepared.”

 

The insurer contended that as the insured is able to perform more than 3 “activities of daily living”, his condition does not meet the criteria of Permanent Total Disablement as required by the policy. 

Nevertheless, based on the medical report from the attending doctor dated 28 September 2016, the Case Manager observed that:-

1. The insured’s condition was attributed to a motor-vehicle accident that occurred on 25 August 2015;
2. The insured is suffering from Permanent Total Disablement due to the accident; and
3. Based on the attending doctor’s last assessment on 28 January 2016, the insured will require assistance in performing activities of daily living such as transfer, mobility, dressing and bathing/washing. 

 

In the medical report it was reported that the insured will require assistance in performing activities such as transfer, mobility, dressing and bathing/washing. Thus, the fact that the insured requires assistance showed that the injury/disablement had prevented the insured from performing the activities.

Based on the above observation, the Case Manager requested the insurer to review the claim

 

Settlement

The insurer agreed to review and settled the claim.