Not a pre-existing medical condition after all

Helen had suffered from indigestion for years and had, from time to time, taken prescription medication to relieve the symptoms. In November 2019 Helen went to her doctor because she was experiencing heartburn and pain on her first mouthful when eating. Helen’s doctor prescribed the same medication, ordered some blood tests, and told Helen to come back if she did not improve. The blood tests returned a normal result.

About a week later Helen and her husband booked a trip to Europe and purchased travel insurance.

Towards the end of December 2019 Helen found that food was ‘sticking’ when she tried to swallow. Helen returned to her doctor who immediately referred her to a specialist, concerned that she might have cancer. In January, the specialist unfortunately diagnosed Helen with cancer and Helen started treatment for cancer.

On her doctor’s advice, Helen cancelled her trip. Helen submitted an insurance claim for the lost accommodation and travel costs. When the claim was declined, Helen complained to FSCL.

 

Dispute

The insurance policy excluded cover for loss caused by a pre-existing medical condition. The insurer said that, because Helen had been to her doctor with signs or symptoms that later proved to be cancer, this was a pre-existing medical condition and not covered by the policy.

Helen said that when she went to the doctor in November, she thought she had indigestion. Although Helen’s doctor had told her to come back if the symptoms did not improve, Helen said that doctors always say that and there was no suggestion that her doctor thought she might have cancer. As Helen had had indigestion in the past, the medication she had been prescribed was not new for her. Helen did not think there was any reason to tell her insurer about what she considered to be a routine visit to her doctor that satisfactorily resolved her problem.

 

Review

We looked at Helen’s medical records and could not see any suggestion that Helen’s doctor thought her symptoms were anything more than a reoccurrence of her indigestion. We also looked at the questions Helen was asked as part of the medical questionnaire in the insurance application process. Helen was asked: “Do you have any undiagnosed signs or symptoms where you have yet to seek medical opinion, or are under investigation, or are awaiting specialist opinion?” Helen had answered, “No”, and we considered this was the correct answer.

We went back to the insurer and asked them to reconsider Helen’s claim.

 

Resolution

The insurer decided to overturn their decision to decline the claim and to pay Helen for her loss. The insurer considered there was enough doubt around Helen’s visit to the doctor in November for them to be satisfied that both Helen and her doctor believed Helen’s symptoms were a reoccurrence of indigestion, which would be covered by the policy.

Helen was delighted with this outcome.

 

Insights for consumers

It is often difficult to know how much an insurer wants to know about any pre-existing medical conditions you have. It is best to err on the side of caution and tell insurers about any recent visits to your doctor, any medical appointments you are waiting for, and any medications you are taking.

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