Case Study: Different benefit amounts for Temporary Total Disablement and Temporary Partial Disablement
The insured was a businessman who frequently travelled between Hong Kong and the Mainland of China. He sustained a back injury due to a fall at work in October 1998. A scan of lumbar spine confirmed a disc herniation. In January 1999, he received laminectomy in a hospital in Shanghai. Medical reports respectively dated April and June 1999 from the insured’s attending doctors confirmed that he still had right thigh and left
toe pain/numbness and could not walk for a long distance. Medical certificates also stated that he was unable to perform any work until 15 July 1999.
The insurer had already paid the insured 159 days’ Temporary Total Disability benefits. However, having learned from the medical examiner that the insured’s range of trunk movement had reached three quarters of his normal range since 15 May 1999, the insurer then decided that the insured was only entitled to Temporary Partial Disability benefits. This was because his present condition would not prevent him from performing his duties.
Facing conflicting medical opinions from the insured’s attending doctors and the insurer’s in-house medical consultant, as to whether the injury had prevented the insured from performing any of his duties or not, the Complaints Panel was inclined to believe that the insured’s attending doctors were in a better position to comment on the health condition of the insured, and thus put more weight on their views. As such, the Complaints Panel ruled that the insured should continue to receive Temporary Total Disability benefits from 15 May to 15 July 1999.
Remarks: as a personal accident policy normally provides different benefit amounts for temporary total disablement and temporary partial disablement, it is important to determine which of these the insured person has sustained.