Council worker wins dispute over halted income payments

A council employee suffering a heart condition has won a dispute over benefits that were stopped when a fund trustee judged that she was able to return to sedentary work.

The complainant was receiving income protection benefits from a discretionary mutual fund administered by the financial firm after a claim was accepted for the illness angina with significant coronary atherosclerotic disease of moderate severity.

The payments were discontinued in November 2021, but the complainant argued they should have been paid until February 16 the next year.

The Australian Financial Complaints Authority (AFCA) says the treating cardiologist provided several letters. One says he is not familiar enough with her employment to pass comment on her capacity to work, but she could manage a job that did not require exertion.

A follow-up report was provided to clarify some issues in November after the fund cut off benefits. It says medication has “not yet been fully effective in abolishing her symptoms, which is what is stopping her from returning to work” and further intervention could be considered in a couple of months.

“In summary, therefore, she is still limited by her coronary disease and will not be able to work for at least two months,” the November 19 report says.

The trustee had the complainant assessed by a medicolegal consultant cardiologist.

AFCA says it’s clear the consultant thought she shouldn’t return to work until a review by her cardiologist in February. A view that she “could do a sedentary job” is qualified by the opinion that her underlying symptoms could recur or be aggravated, and that she shouldn’t work while symptomatic, it says.

The complainant provided a series of medical certificates that said she was unfit to work.

AFCA says trustee letters show it relied heavily on doctors’ statements that the complainant was fit for sedentary work, and on advice from the council that her job was sedentary.

“There was some debate about how much physical work was required in the complainant’s job. Ultimately, that misses the point,” the decision against JLT Risk Solutions says.

“The trustee does not appear to have grappled with the fact that all doctors involved in the case ultimately concluded that the complainant should not work. If she had returned to work, it would have been against the advice of four doctors, including her treating specialist and a consultant cardiologist.”

AFCA says the trustee’s decision “was not open to it on the evidence before it” and it must treat the complainant as suffering temporary total disablement for the period to February 16 2022 and pay benefits accordingly.

The decision is available here.