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