- The National Financial Ombud Scheme found that the cancer itself was the decisive life-changing event for the complainant, not the later confirmation through lab results.
- Discovery Life argued that the claim only arose when invasive breast carcinoma was medically confirmed on 21 October 2023, after the cover had already lapsed.
- The ombud found that symptoms and medical evidence showed the illness was already present while the policy was active and premiums were still being paid.
A cancer patient has won a dispute against Discovery Life after the National Financial Ombud Scheme decided that the illness itself, rather than the later paperwork confirming the diagnosis, determined when the claim event happened under a Severe Illness Benefit policy.
The dispute was about Discovery Life’s refusal to pay a Severe Illness Benefit claim for cancer. The insurer did not argue that the complainant had invasive breast carcinoma. The main issue was when the life-changing event legally took place.
Discovery Life said the event only took place on 21 October 2023, when lab tests confirmed the cancer diagnosis. By then, the insurer claimed, the complainant’s cover had already lapsed because premiums had not been paid.
The matter went to the National Financial Ombud Scheme, where Denise Gabriels, Lead Ombud of the Life Insurance Division, disagreed with Discovery Life’s reading of the policy wording.
Gabriels noted that the policy itself does not say that a life-changing event only happens once there is medical confirmation.
Gabriels said, “Discovery Life has yet to point to the provision in the policy which stipulates that a life-changing event is deemed to have occurred on the date medical confirmation of a covered condition has been received.”
She added, “In the absence of a deeming provision, the date of the life-changing event is the actual date of occurrence. If the evidence proves that the insured met the qualifying criteria of the disease covered by the policy when the policy was in force, the insurer is liable.”
Background to the dispute
The evidence before the ombud showed that the complainant had a breast biopsy on 18 October 2023. The sample was received on 19 October 2023, and the pathology report confirming invasive breast carcinoma came out on 21 October 2023.
Discovery Life relied on the 21 October date as the official trigger for the claim. The insurer said its policy terms required objective medical confirmation and lab verification before a valid Severe Illness Benefit claim could be made.
In its submissions to the ombud, Discovery Life said, “The mere presence of symptoms, even if clinically suggestive, does not suffice to meet the contractual threshold for a valid claim under the Severe Illness Benefit.”
The insurer insisted that the policy wording clearly tied the claim event to formal medical confirmation rather than earlier symptoms or clinical suspicion.
Findings of the ombud
Gabriels found that the insurer’s interpretation was not backed by the wording of the policy. She said, “The fact that the proof, medical confirmation and histological verification, was received when the policy was out of force does not exclude a valid claim which arose when the policy was in force.”
The ombud found that the complainant had already experienced symptoms in September 2023 while premiums were still being paid and cover was still active.
Gabriels said, “The evidence showed that the complainant had experienced symptoms in September 2023 when the premiums were paid. These symptoms, together with the medical investigations, were consistent with and confirmed by the diagnosis of cancer in October 2023.”
The National Financial Ombud Scheme ultimately decided that the complainant met the qualifying criteria for the disease while the policy was still in force. Discovery Life was ordered to pay the claim and complied with the ruling.
This decision reinforces the idea that in Severe Illness Benefit disputes, the illness itself can determine when a claim event happens if the policy wording does not clearly state that diagnosis confirmation is the deciding factor.
Get your news on the go. Click here to follow the Conviction WhatsApp channel.
