Luis and Aoife were staying at a resort in Cancun, Mexico. One night, they went out drinking and dancing and came home because Aoife’s knee was starting to hurt.
Aoife had had knee surgery in the past year and was prescribed codeine pills. She took two pills, got into bed and fell asleep. Soon after, Aoife let out a big sigh and stopped breathing.
Luis noticed Aoife was starting to turn blue and called for help. Luis gave Aoife rescue breaths until hotel medical staff arrived.
Aoife was rushed to hospital in an ambulance. In the ambulance, Aoife was given more oxygen and a drip. By this time, Aoife had regained consciousness but was having trouble breathing on her own.
The hospital staff told Luis it would cost USD 8000 to admit Aoife to intensive care. While Luis phoned his insurer to seek permission, Aoife discharged himself from hospital and refused further treatment.
Luis and Aoife received a medical bill from the ambulance and hospital for the costs of consultation and medical care. They made a claim to their travel insurer, who declined to pay the medical costs.
The insurer said that Luis’s insurance policy clearly excluded claims arising “directly or indirectly” from alcohol consumption. The insurer relied on ambulance and hospital documents that recorded that Aoife was intoxicated and had taken codeine.
Luis complained to FSCL.
Dispute
Luis said that he had purchased travel insurance for peace of mind. He thought it was unfair that he saved Aoife’s life, but the insurer would not pay out the medical claim.
Luis argued that Aoife was not intoxicated, and that the insurer was wrong to rely on the medical documents from Cancun. There was no blood test, so the insurer could not rule out codeine as the principal cause of Aoife’s symptoms, rather than alcohol.
However, Luis admitted that Aoife had consumed approximately four drinks on that day, and they had been drinking and dancing.
Review
Upon review, we found that the insurer had relied on a poor translation of the Spanish medical documents. There were several mistakes in the translated copy which inaccurately described Aoife’s symptoms and presentation.
However, we agreed with the insurer that Luis’s policy did not cover Aoife’s medical costs. This was because, Aoife had told us she had been taking codeine for approximately one year without any side-effects. However, on this occasion she had suffered severe side-effects after she had also consumed alcohol.
In our view, it was most probable that Aoife’s symptoms had been caused by a combination of alcohol and codeine, rather than codeine alone. As we did not have any blood tests from the hospital to tell us what Aoife’s blood alcohol level was, we made our decision on the balance of probabilities, and Luis’s admission.
Resolution
Unfortunately, Luis’s policy clearly excluded any claims arising directly or indirectly from alcohol use. We recommended to Luis that he withdraw his complaint and explained our reasoning.
Although Luis was very disappointed, he agreed to withdraw his complaint.
Insights for consumers
In this case, Luis’s insurance policy clearly did not cover him for losses arising out of alcohol consumption.
An insurance policy is a contract between you and the insurer which explains the risks the insurer is willing to cover you for in exchange for a premium. It is important to read the policy wording carefully and keep evidence of any potential claims.
