When deciding on a disability benefit, the trustees of your retirement fund have a responsibility to carefully consider the medical reports before them. In particular, they need to watch out for factual inaccuracies and inconsistencies which bring the credibility and accuracy of medical reports into question.
Mamodupi Mohlala, the Pension Funds Adjudicator, recently ordered the trustees of a fund to set aside their decision to turn down a disability claim. This was after the fund member contested the accuracy of the medical report that formed the basis for the decision to repudiate the claim.
The member, Ms H, was employed by Safcor Panalpina as a forwarding clerk.
She was diagnosed with a lung disease and declared permanently disabled, according to her supporting medical reports.
However, the trustees of the Bidcorp Provident Fund and the fund's administrator, Alexander Forbes, were adamant that Ms H did not qualify for a disability benefit.
They deferred to the insurer, Old Mutual, which repudiated the claim.
Fund's rules
But the adjudicator found that, according to the rules of the fund, the trustees - and not the insurer - "have a duty to determine whether or not a member is permanently incapable of efficiently discharging his or her duties through infirmity of the mind or body, premised on medical advice".
The decision to repudiate the disability claim was based on a physician's assessment of the member's medical records, including one report by an independent occupational therapist who examined Ms H and suggested that she was moderately impaired and able to go back to work.
The adjudicator noted that this report contained factual inaccuracies that could have an impact on the medical assessment.
Series of inaccuracies
The inaccuracies and inconsistencies identified were as follows:
- The report is signed and dated July 11, 2007, but refers to reports subsequent to that - namely, July 17, 2007 and October 23, 2007.
- The member's date of birth is recorded as April 10, 1977 and in the same report she is alleged to have completed Grade 10 in 1976, the year before she was born.
- The physician who assessed the member's medical reports is said to have discussed the member's condition with Dr MP in July and Dr MP is said to have indicated that Ms H could return to work.
But in a written report dated July 25, 2007, Dr MP recommends the exact opposite.
Adjudicator's decision
Due to these inconsistencies and inaccuracies, the adjudicator ruled that the medical report could not be relied on and the decision of the trustees could not stand.
She ordered that:
- The trustees refer the assessment report to the occupational therapist - or an alternative independent occupational therapist - for corrections and amendments, within 30 days from the date of the determination.
- The trustees exercise their discretion and make a determination in terms of rule 30.1 on the ability of Ms H to discharge her duties.
They must reach a decision within 14 days after receiving the assessment report from the occupational therapist.
- The decision by the fund trustees together with the assessment report should be communicated to Ms H, the insurer and the Office of the Pension Funds Adjudicator within 14 days of receipt of the assessment report.
Contact
The Pension Funds Adjudicator is Mamodupi Mohlala.
Cape Town office:
Telephone: (021) 674 0209
Fax: (021) 674 0185
email: [email protected]