John and his son Oliver took a trip together to Europe to join a tour. A few days into the tour, John began feeling unwell. John was taken to hospital where it was discovered that he had deep vein thrombosis and a pulmonary embolism. John and Oliver had to cut their trip short and fly home. After a number of days in hospital the doctor’s assessed that John was fit to fly but recommended that John should keep his legs stretched and elevated during the flight.
Oliver and John called their travel insurer and provided the insurer with the doctor’s recommendation. The parties discussed the possibility of upgrading John’s seat to business class to allow space for his legs to be elevated.
After assessing all the information on John’s mobility, his medical notes and the insurer’s own internal medical guidelines, the insurer decided that John was fit to fly in economy class back to NZ. It declined to upgrade his seat to business class. The insurer believed that being in economy, but getting up and regularly walking, would be just as beneficial to John’s legs as having them elevated.
When John and Oliver heard of the insurer’s decision, they decided they would pay for John to be upgraded to business class. However, when they went to purchase the seat, there was no business class seat available. John and Oliver returned to NZ in economy class.
John and Oliver complained to FSCL about the service they had received from the insurer.
Dispute
John and Oliver believed that the insurer had provided poor service in a number of respects. Firstly, they said that the insurer should have listened to the advice of the overseas doctors who recommended that John’s legs be elevated on the trip home. Secondly, the insurer failed to pay the hospital fees as they had guaranteed. Instead, John was made to pay the bill himself and then seek reimbursement from the insurer, and reimbursement was delayed.
The insurer disputed the overseas doctor’s assessment that John needed to have his legs elevated. The insurer based their decision in reliance on their internal medical guidelines that said that the best way to repatriate a person with John’s condition was to ensure that they are able to be mobile during the flight, rather than laid flat with legs elevated as had been recommended by the overseas doctors.
The insurer said that it had been unable to make direct payment to the hospital as the hospital would not accept its payment guarantee. This was why the insurer had required that John make payment to the hospital himself and seek reimbursement from the insurer afterwards. The insurer acknowledged that there had been a delay in reimbursing John.
Review
We reviewed the medical evidence and the insurer’s policy and found that the insurer was entitled to rely on its internal medical guidelines. However, the insurer could have conveyed its decision to John and Oliver better and explained why it believed that mobility was more important than leg elevation in ensuring that John could safely travel.
While the hospital did refuse the insurer’s payment guarantee, we found that the insurer could have paid by credit card had it operated with more urgency, rather than requiring John to pay the hospital.
Resolution
We considered that although the insurer was within its rights to make a decision according based on its internal medical guidelines, its conduct had caused stress and inconvenience to John and Oliver. We recommended that the insurer pay John $500 compensation. Both parties accepted this recommendation.
Insights for participants
It is important for insurers to be aware of how they convey their decisions to their customers, particularly in times of high emotion and stress. In John’s case, a decision was made based on the insurer’s internal medical guidelines but that departed from what the customer had been told by doctors. If the insurer had properly informed John of the reasons behind the decision, this would have helped in alleviating the added stress and fear that the family felt when they were told that John would not be able to fly business class.
