A KwaZulu-Natal Mother has approached the High Court in Durban seeking to review a National Financial Ombud Scheme South Africa (NFO) Appeal Tribunal ruling that refused her leave to appeal after Momentum Metropolitan Life rejected her insurance claims.
The mother of two is challenging the September 16, 2026, ruling, which upheld an earlier NFO decision dismissing her complaint relating to two long-term insurance policies, including a R10 million Myriad Functional Impairment Benefit, IOL reported.
The application names Momentum, the National Financial Ombud Scheme South Africa and the judge of the NFO Appeal Tribunal as respondents.
The nurse argues that the appeal tribunal made material errors of law and fact, failed to properly consider relevant evidence and did not correctly apply section 59 of the Long-term Insurance Act.
The dispute centres on claims linked to the absence of her left kidney, respiratory problems following a workplace incident and alleged non-disclosure of medical information when she applied for the policies.
Two Momentum policies
The nurse held two risk-benefit policies with Momentum Metropolitan Life.
The first was a Myriad Functional Impairment Benefit, with a benefit amount of R10 million, which commenced on June 1, 2023.
The second was a Complete (Enhanced) Critical Illness Benefit, which commenced on July 1, 2023.
She lodged claims under both policies after being diagnosed with left unilateral renal agenesis on July 5, 2023.
Momentum declined the claims on August 7, 2023.
The nurse also sought cover for respiratory impairment after an injury at work on May 29, 2023, when she inhaled toxic fumes.
Why Momentum rejected the claims
Momentum's position was that the missing kidney did not meet the defined events covered by the Functional Impairment Benefit.
While Momentum accepted that the nurse had left unilateral renal agenesis, meaning she was born without a left kidney, it said the policy covered specific renal conditions, such as end-stage renal disease or permanent dialysis. Her remaining kidney was functioning normally, with normal laboratory results, and she was not undergoing dialysis or other relevant treatment.
The policy cover did not exclude congenital anomalies.
The critical Illness policy also did not specifically provide cover for renal agenesis in the circumstances of her claim. The NFO appeal tribunal found that the relevant section required conditions involving ongoing therapy or surgical intervention, which the evidence did not establish.
In relation to the respiratory claim, Momentum maintained that the required level of impairment had not been established.
The nurse said she had submitted four lung function tests and a claim form for the respiratory condition, but it was ignored by Momentum
Momentum also relied on alleged non-disclosure when the nurse applied for the policies.
According to the appeal tribunal, she had answered “No” to questions concerning matters including psychological consultations, depression, stress or anxiety, respiratory conditions, illnesses or disabilities, diagnostic tests, planned medical visits and certain medication.
Momentum's investigation allegedly uncovered medical records relating to some of these matters.
The allegations of depression , stress , anxiety were overturned by a psychologist who confirmed she did not suffer from any of these conditions and neither were there any diagnostics done to determine such diagnosis.
The appeal tribunal accepted Momentum's position that the questions on the application forms were clear and that the alleged non-disclosures were material to the insurance risk.
Nurse challenges interpretation of kidney condition
The nurse argues that the appeal tribunal focused too heavily on whether the words “renal agenesis” appeared in the policy instead of properly interpreting the contractual provisions dealing with functional impairment and organ function.
She says Momentum should consider the anatomical absence of her left kidney, the loss of that kidney's function, compensatory hyperfiltration, her total renal function and the contractual threshold contained in the Functional Impairment policy.
She also questions whether normal laboratory results from her remaining kidney necessarily answered the contractual question of whether she had suffered a permanent loss or impairment.
The nurse argues that the Functional Impairment policy expressly refers to permanent conditions and functional impairment and said this should have been distinguished from the Critical Illness policy.
She disputes the tribunal's statement that “permanence is not the insured event”.
However, the appeals tribunal previously found that the nurse's argument incorrectly approached the matter from the perspective of exclusions.
The ruling found that the policies were “defined-event products”, meaning that an insured person first had to establish that their condition fell within one of the events positively covered by the policy.
The absence of an exclusion for congenital renal agenesis therefore did not create cover where the condition was not otherwise included as an insured event.
Dispute over assessment of respiratory impairment
The respiratory claim is another key part of the review application.
The nurse said four pulmonary-function tests showed severe restriction, with FVC results ranging between 40% and 50%.
The appeal tribunal found that the required level of impairment had not been established and characterised the dispute as one involving the weight to be attached to competing medical reports.
The nurse argues that the issue was not simply a disagreement over medical evidence, but involved the interpretation and application of the policy.
She says the Tribunal should have considered each pulmonary-function test, its date, the FEV1, FVC and DCO/DLCO results, the applicable policy threshold and whether the individual results established the insured event.
Dispute over alleged non-disclosure
A central issue is Momentum's reliance on alleged non-disclosure.
The appeal tribunal found that the nurse had failed to disclose information relating to, among other things, psychological consultations, depression, stress or anxiety, respiratory conditions, illnesses or disabilities, diagnostic tests, planned medical visits and certain prescription medication.
The Appeals tribunal is relying on information from a general practitioner who had given her non medically trained staff to complete a PMA document with incorrect information and the Doctor was also found guilty by the HPCSA for unprofessional conduct .
All of which was over turned from treating doctors stating that she did not suffer from anxiety , depression or any cardiac condition and submitted letters to Momentum however Momentum still declined the claim.
The tribunal held that section 59(1)(b) of the Long-term Insurance Act applied an objective test and that dishonesty or an intention to conceal information was not required for non-disclosure to be material.
The nurse challenges this reasoning.
She argues that section 59 contains separate requirements that should not be collapsed into a single enquiry.
According to her application, the court must determine what information existed at the time of each application, whether that information fell within the particular question asked by Momentum, whether it was material and whether it was likely to have materially affected the assessment of the relevant risk when the policy was issued.
She argues that establishing that information ought to have been disclosed does not, by itself, satisfy the statutory requirement of materiality.
Moreover, she argued that further information was submitted that Momentum' reasons to deny her claim could no longer be valid. However, the insurer kept moving the goal post.
"Momentum found other new reasons to validate why they declined the claim," she said.
Timing of medical information disputed
The nurse also places significant emphasis on the chronology of the applications and medical information.
Her Functional Impairment application was submitted on May 23, 2023, followed by the workplace incident involving toxic fumes on May 29. The Functional Impairment cover started on June 1.
Her Critical Illness application was submitted on June 9, while a pulmonary-function test was conducted on June 20. The Critical Illness cover commenced on July 1.
She was diagnosed with unilateral left renal agenesis on July 5, while another pulmonary-function test was conducted on August 1.
The renal claims were declined on August 7.
The nurse argues that this chronology is important to the section 59 enquiry because information that arose after an application could not simply be treated as information that she had withheld when applying for cover.
She says the Tribunal failed to adequately distinguish between information that was known before each application and information that arose afterwards.
Momentum's investigation and policy changes
The nurse also questions Momentum's post-decline investigation.
She questions why Momentum's forensic investigator sought historical medical information from a former colleague after her claim had already been declined, and whether that information was subsequently used to strengthen the reasons for rejecting her claims.
The dispute further concerns Momentum's treatment of the two policies.
In November 2023, Momentum offered to reconstruct the Functional Impairment policy by adding a mental-health exclusion. The policy was subsequently cancelled from January 1, 2024.
The Critical Illness policy was cancelled from inception, with Momentum refunding R4,819.08 in premiums.
The Appeal Tribunal found that the reconstruction was lawful and reasonable and regarded the cancellation of the Critical Illness policy as an underwriting judgment supported by Momentum's evidence.
The nurse disputes this conclusion and wants Momentum to produce the underwriting manuals, guidelines, rules, risk categories and other evidence showing what it would actually have done had the alleged non-disclosures been made.
She argues that Momentum should establish whether it would have declined the cover, imposed an exclusion, increased the premium or otherwise altered the policies.
The nurse also challenges the apparent reliance on her occupation.
She argues that the fact that she was employed as a bill auditor but did not practice as a nurse and worked in a Patient Services department did not, by itself, establish that she knew particular medical information was material to Momentum's underwriting assessment.
Leave to appeal challenged
The nurse is also challenging the decision to refuse her leave to appeal.
The appeals tribunal previously found that there were no reasonable prospects of the appeal tribunal reaching a different conclusion from the Ombud and refused leave to appeal.
The nurse argues that the tribunal should not simply have concluded that there was no reasonable prospect of a different outcome.
She said it should have separately considered the legal errors, procedural issues and interests-of-justice grounds raised in her application.
Momentum responds
In its response, Momentum said it empathised with the nurse’s circumstances and was aware that she was seeking a High Court review of the matter.
The insurer said the claims were submitted shortly after the policies began in 2023 and that it had explained on several occasions why they were declined.
“An independent and impartial consumer body, the National Financial Ombud Scheme South Africa (NFO), considered the matter twice and ruled in Momentum’s favour on both occasions,” the insurer said.
Momentum said the NFO’s submissions and responses set out the positions of the parties in detail.
“As the matter is now before the High Court, Momentum will respect the legal process and will not comment on the merits of the case or the specific allegations raised,” it said, adding that it also had to protect the nurse’s confidentiality.
The insurer said the court was the appropriate forum to consider the dispute.