TESTIMONIALS

temporary health - ‘disabled' - evidence that policyholder engaged in activities conflicting with his statements - whether insurer justified in ceasing claim payments.

The claimant, Mr. John received monthly benefits from the firm after it accepted his disability claim in June March 1998. His case was reviewed periodically and his disability was described as a ‘non-specific' problem, which caused him to feel unwell and exhausted, with aching muscles and weakness. His doctor confirmed that his condition remained static and that he was suffering from ‘psychogenic pain unspecified'.

The firm arranged for another doctor, Dr. X, to examine Mr. John at his residence. Mr. John told Dr. X, that he spent most of the day either sitting on a chair and staring into outer space or sitting outside in the garden. Mr. John also said that he needed help to load groceries into his vehicle and had not been able to drive for two to three months.  However, Dr. X could not find anything wrong with him.

EPIS, Sub Rosa Investigators filmed the claimant, Mr. John in the weeks before and after Dr. X's visit. These videos showed the claimant getting out of his car, opening the trunk without any difficulty, pushing a supermarket trolley and loading groceries into his vehicle, without any sign of hesitation or limitation.  Investigators also videotaped him washing and waxing his vehicle before driving for a long distances.

Sub Rosa investigators concluded that the claimant Mr. John did not satisfy the policy definition of being ‘disabled' and it stopped the benefit payments. In response, the claimant presented the firm with a letter from his Doctor saying that his condition had deteriorated. The Doctor did not appear to have been aware of the video evidence of the claimant's activity, or of why the adjuster had stopped the payments.

Complaint rejected
we were satisfied that our Sub Rosa investigator's had acted fairly. We did not think that the claimant was medically unable to perform his normal occupation.  He had been unable to explain either the level of activity shown in the videos or the disparity between this activity and his statements to Dr. X, about what he could - and could not - do.