SANTAM YOUR DEFENCE IS WEAK

Good day Stephan,

Thank you for your response and condolences. I have emailed you the details.
Kind regards,

Giuliana Claasen

SANTAM AND TIC we met the criteria according to your policy wording for submitting a claim and each time you rejected and changed the criteria for assessment. Policy wording is there for a reason. My mother was over the age of 70 but did not pass away from a pre-existing nor cardiovascular condition. She passed away from pneumonia. Your first rejection: My mother’s age and reason for hospitalisation ie. Stroke. This was not the cause of of death as stated on the death certificate. Reason for hospitalisation and cause of death are not always interchangeable. The death certificate has the final word – it stated pneumonia and cardiac arrest. Your second rejection: now the death certificate was admissible – cardiac arrest. But when I proved cardiac arrest is not cardiovascular you then requested the medical records. Your third rejection: was now based on complications that arose from having had a stroke – pneumonia – as stated on the death certificate. The policy does not make provision for complications but rather conditions. These two words are also not interchangeable. So each time the basis for the rejection was changed because it did not yield a favourable outcome for the company clearly showing inconsistency in your approach to claims.

This brings me to your verdict of 'complications from a stroke.' Your policy wording does not make provision for complications, only conditions. I stand by my original statement that your defence is weak - owing to the lengths you went to avoid a payout when all evidence suggested otherwise. First using the argument of Cardiac Arrest- which turned out not to be cardiovascular. When that failed you requested medical records to prove a pre-existing condition - which there wasn't. When that failed you were left with no choice but to go the complications route, and to further strengthen your argument, my mother’s age. The message that this sends out is two-pronged: that SANTAM and their travel insurance arm are not inclined to honour their claims even when presented with evidence to the contrary, and that people over the age of 70 do not form part of their business model, or reluctantly so.
Your policy wording states: Section 4.1: Journey cancellation & 4.2 Journey curtailment - we will pay for or reimburse You the non-refundable portion of travel....as a result of one of the following: 1. Unforeseen, unexpected and sudden death of...Your Immediate Family. Medical reasons for cancellation must not be relating to a pre-existing medical condition. There was no pre-existing medical condition - as was confirmed by the medical professional treating my mother. But this did not further your aims given that you continued to relentlessly pursue a different reason to reject. Section 4: Exclusions - we will not pay for any claim arising from
" g. vascular, cardiovascular or cerebrovascular conditions .... a member of your immediate family is over the age of 70 years." Nowhere in this wording does it state complications. Again I refer to the definition of a medical condition vs a medical complication - the one is as a result of another and can never mean the same thing. Complications arise from incorrect treatment or negligent care. "A complication in medicine, or medical complication, is an unfavorable result of a disease, health condition, or treatment." source: wikipedia.org I provided the death certificate, as requested, to show that cause was not a stroke. It stated pneumonia and cardiac arrest. The death certificate did not state a vascular, cardiovascular or cerebrovascular condition. We already know that cardiac arrest is not related to cardiovascular disease. So, I reiterate - based on your policy wording we have fulfilled all the conditions for our claim to succeed, yet you have again sought to find reasons to reject it: 1. Cause of death, not related to a pre-existing medical condition (see letter of Dr. Thom) 2. Cause of death, though over 70, not a cardiovascular condition (see death certificate) I was asked to supply a death certificate showing cause (not complications) as well as medical history. I comp****. In the final analysis, my mother passed away at the age of 82 from pneumonia and had no pre-existing cardiovascular or related medical condition. I have proved this. You, however, have chosen to interpret your policy wording to suit your own ends.

In conclusion, I would like to express my gratitude to the office of the Ombudsman for attending to my case so speedily and returning a favourable verdict. They helped to lighten our load in this time of immense sorrow.