No cover for pre-existing medical conditions

In 2018, Aida purchased student travel insurance for her university student exchange to New Zealand. While in New Zealand, Aida ended up in hospital with a uterine myoma and had to pay a hospital bill of $4000. Aida claimed on her insurance to recover this cost.

Aida’s insurer declined her claim because her medical expenses arose from a pre-existing medical condition. When issuing Aida’s policy, her insurer had specifically sent her an existing medical condition form (EMC) which excluded cover for uterine myomas. The form contained this exclusion because Aida’s medical history had shown that she was being monitored for this condition in her home country.

When her claim was denied, Aida brought a complaint to FSCL.

 

Dispute

Aida complained that the insurer had incorrectly declined her claim and caused her stress. Aida said that she had never discussed having a uterine myoma with doctors in her home country and that she did not have a history of this condition. She alleged that the insurer had contacted her doctors without her permission and that, as she had never signed the EMC form, it did not apply.

The insurer disputed Aida’s claim. The insurer said that they had not contacted Aida’s doctors. Aida had provided the insurer with supporting medical information in her application which included the reference to her uterine myoma. The insurer claimed that the EMC did not need to be signed by Aida, and that even without the EMC, Aida would not have been covered for this pre-existing medical condition.

 

Review

We reviewed the evidence and found that the insurer had applied the policy correctly. The insurer had relied on the information provided by Aida which clearly referred to her having a history of uterine myomas. We found that it did not matter that Aida had not signed the EMC form.

We did find that the insurer should have ensured its broker had properly explained to Aida that she would not be covered for the uterine myoma. If this had been properly explained, Aida would have understood that she was not covered and could have avoided the stress of pursuing the claim and complaint. We recommended that the insurer compensate Aida $250 for stress and inconvenience.

 

Resolution

We upheld the insurer’s decision to decline the claim, but awarded Aida $250 for stress and inconvenience. The insurer reluctantly accepted this recommendation and paid Aida the $250. Aida was unhappy with this result but eventually accepted the settlement.

 

Insights for consumers

It is important when purchasing insurance to properly disclose any pre-existing medical conditions to your insurer. Failure to do so, will mean that the insurer can decline your claim.

Search case studies