James and his brother Tim booked a trip to Hawaii together in early 2018. A month before booking the flights and obtaining insurance for the trip, Tim visited a doctor to seek treatment for some respiratory issues he had been having. The doctor referred Tim to a respirologist who concluded that the breathlessness that Tim had been experiencing was due to inflammation in his lung.
A few weeks before the brothers were to leave on their trip, Tim had a check up on the inflammation in his lung and it was discovered that he had lung cancer. Tim and James cancelled their trip.
When James claimed on his insurance for the cost of the cancelled trip, he was declined. The insurer concluded that Tim’s lung cancer was a pre-existing medical condition, which had not been disclosed.
Dispute
The parties disputed whether the lung cancer was a pre-existing medical condition.
The insurer claimed that although Tim did not have a definitive diagnosis of cancer before the trip was booked, it believed Tim had been made aware of the possibility of such a diagnosis at the earlier doctor’s appointment. This belief was based on a doctor’s note from the first appointment, which stated that Tim had received counselling during his visit to discuss his scans. The insurer said this indicated Tim had been given a probable diagnosis of cancer at the first appointment.
Tim and James disputed this finding. Tim said at the first appointment there had been no counselling about cancer, merely a discussion on a few changes that had occurred in Tim’s personal life. The brothers claimed they had no knowledge of any cancer diagnosis until the subsequent appointment, which occurred after the flights and the travel insurance were purchased.
James complained to FSCL about the insurer’s decision on his claim.
Review
We gathered all the medical evidence from Tim’s various doctor’s visits. After analysing the medical evidence, we found that Tim’s lung cancer was not a pre-existing medical condition. The evidence showed that the doctors visits’ Tim attended before the policy was purchased were to investigate a non-related mass in Tim’s lung. The later discovery of the cancer was found in a different part of Tim’s lung and was only discovered while the non-related lung mass was being investigated.
The insurance policy only precluded cover if Tim had received medical advice about the actual condition which caused the trip to be cancelled (cancer), prior to the insurance policy being purchased. However, the condition Tim received medical advice about prior to purchasing the policy was a non-related lung mass and, importantly, that discovery was only made after the policy was purchased. This meant the cancer was not a pre-existing medical condition.
Resolution
We recommended that the insurer should accept James’ claim. The insurer agreed and refunded James the cost of his trip ($1300). James was pleased with the result.
Insights for participant
Each claim will be based on slightly different facts. It is important that insurers carefully analyse the medical evidence of each claim to ensure the facts actually support the decision to decline a claim.
