Is being tired a pre-existing medical condition?

Janie visited her doctor over the course of 2017 due to symptoms of decreased mobility, fatigue and hip pain. Janie was supposed to travel to Europe next year with her daughter and was concerned about her symptoms. Janie’s doctor prescribed medication and B12 injections to assist with her tiredness.

In mid-2017, Janie purchased her tickets and bought travel insurance for her trip to Europe. She was advised to disclose any pre-existing symptoms but did not disclose the treatment she had sought for fatigue and hip pain.

After a year of unexplained symptoms of fatigue and joint problems, a rheumatologist diagnosed Janie with primary fibromyalgia. Janie’s doctor advised her to defer her travel plans in order to avoid aggravating the pain. Following her doctor’s advice, Janie and her daughter cancelled both their travel arrangements to Europe.

Janie filed a claim with her insurer for her unused travel costs. She also made a claim for her daughter’s travel expenses. 

The insurer declined Janie’s claim because her policy wording excluded cover for a pre-existing medical condition that had not been assessed and accepted for cover. It also declined cover for her daughter which Janie accepted.

Janie complained to FSCL about her claim being declined.

 

Dispute

Janie argued the insurer was incorrect to base its decision on pre-existing symptoms of fatigue and joint problems which could be linked to a number of medical conditions. Janie had not received a diagnosis before purchasing travel insurance cover, and therefore had no pre-existing conditions to disclose.

Janie said that, while everyone has symptoms of some kind when taking out insurance, they are not a “condition” until they are diagnosed.

 

Review

Upon review, we found that the insurer was correct in declining Janie’s claim as her claim was due to a pre-existing medical condition.

Under her insurance policy, to have cover for her diagnosis of fibromyalgia, Janie was required her to disclose any sickness or condition which had occurred, or that she had sought treatment for, in the past six months. While we accepted that Janie was not aware of a diagnosis when she booked her travel, she had been presenting with joint pain and discomfort, for which she had sought medical assistance. She had also expressed concerns to her doctor about travelling the next year.

 

Outcome

We told Janie that her diagnosis of fibromyalgia was excluded under her insurance policy as it was a pre-existing condition. Janie agreed to withdraw her complaint.

 

Insights for the consumer

While an insured may not be aware of a diagnosis, some insurance policies contain widely defined exclusions which exclude cover where treatment or symptoms of a condition are manifest at the time cover is purchased, and are not disclosed.

It is important to consider the policy wording carefully and disclose any pre-existing medical condition, symptoms or treatment sought prior to purchasing insurance.

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