A complainant whose claim for a critical illness benefit was declined by her insurer, despite suffering neck and shoulder injuries that restricted her ability to dress and bathe unassisted, has succeeded in having the decision overturned.

The injuries led to her having to rely on her daughter and husband to help her dress because of her restricted neck and should movements, and she normally showers 1-2 times per week with support from her daughter.

However TAL rejected the claim on grounds that the complainant has not demonstrated she was unable to perform at least two Activities of Daily Living tasks from a list as set out in the policy’s benefit payment requirements.

The Activities of Daily Living list includes dressing, defined as the ability to put on and take off clothing, and bathing, defined as the ability to shower and bathe.

The list falls under Loss of Independent Existence, described in the policy as significant cognitive impairment or the total and irrecoverable loss of ability, due to sickness or injury, to perform at least two of the Activities of Daily Living without the physical assistance of another person.

TAL provided the Australian Financial Complaints Authority (AFCA) with a physiotherapist’s assessment of the complainant’s capacity to perform Activities of Daily Living tasks.

The physiotherapist, who has many years of experience as an occupational rehabilitation consultant, says if loose fitting shirts and dresses were available the complainant may be able to dress independently. She could also use slip on shoes, he said.

He says having a shower sponge attached to the wall may benefit the complainant as it will allow her to wash her right upper limp by moving against the sponge. He also suggests that a long-handled sponge may also assist her reaching various areas of her body.

But AFCA says the complainant has shown that she is not able to dress and bathe without physical assistance and ruled TAL must pay her the critical illness benefit.

“This is consistent with common sense,” AFCA says in its ruling of the dispute. “Many items of everyday clothing, including importantly bras, have fastenings that are very difficult to operate with only one hand, and can be awkward to put on even with both hands.”

AFCA says the physiotherapist has identified possible mechanical solutions for bathing but is not satisfied they are safe or effective for the complainant or are able to be achieved without significant pain to her.

“On balance, the panel is satisfied that the complainant cannot bathe independently,” AFCA says.

The insurer must also pay her interest calculated from September 1 last year, which is roughly three weeks after her GP provided her most recent report about her medical state. AFCA placed reliance on the medical report in concluding she cannot bathe independently.

Click here for the ruling.