Gauteng High Court (Johannesburg) Judge Ingrid Opperman has ruled interpretations by an insurance company are largely ‘inadmissible’ to a court after the company was challenged by a claimant who suffered a heart attack.

The company only paid him 25% of his total benefit, whereas it should have paid the full amount, the court ruled.

Business Day report notes Neil Delpaul suffered an acute heart attack in 2015 for which he was treated. He lodged a claim for payment from Hollard Life Assurance. Hollard interpreted its contractual policy clauses to mean he was owed 25% of the benefit amount (about R578 000).

After he was paid out in 2015, Delpaul believed he was entitled to the full benefit amount (R2.3m).

Hollard refused to pay and he took the matter to the High Court. Delpaul argued that according to the policy, ‘heart attack’ is one of the ‘events’ listed for which a client should receive 100% of the benefit amount.

Hollard disputed this.

It listed three separate events pertaining to Delpaul: a 2012 heart disease claim, a 2012 claim for a bypass and the 2015 heart attack claim.

The policy stipulates that only one payment can be made per event in particular categories.

Opperman said the reinstatement clause ‘places much reliance on whether the claim was for a related or an unrelated condition’, says the Business Day report.

If a particular type of condition received 100% payout, a person could only claim for a second related condition 90 days after the first claim. However, even then, the second payout would only be up to 25%.

Opperman noted whether the second claim is related and is where the issues actually arose, muddying Hollard’s interpretation.

‘The policy does not provide that once 100% of the benefit amount in a particular (category) has been paid, no further payments will be made for such (category),’ she said.

That means the events listed in the cardiovascular category, for example, are all individual events. That meant Delpaul could notionally claim for every event within the 30-day period.

Opperman said the clause that kicked in to cap him at 25% only relates to the same event within a category. That means this 25% cap should only have arisen if Delpaul claimed for a second stent after the first one in 2012, for example, not for a stent followed years later by treatment for a heart attack in 2015. A stent and a heart attack were different events.

The judge emphasised a company’s interpretation of its own contract is ‘irrelevant’ for a court. ‘It is for a court to interpret the agreement/policy’ and not for a company to, she said.

Opperman ordered Hollard Life to pay the balance of 100% of the benefit to Delpaul, or about R1.7m, and costs.

Full Business Day report

Judgment