Breathless over insurance payout
Brendan had health and trauma cover. His insurance had been arranged for him by his insurance adviser and Brendan had been satisfied with the service.
In March 2015, Brendan felt tightness in his chest and suffered from loss of breath. He went to see his doctor. Brendan’s doctor did some tests and diagnosed Brendan with angina.
Brendan’s angina was caused by a plaque build-up in the walls of the arteries. This build-up narrows the coronary arteries that feed blood to the heart resulting in less blood getting to the heart muscle. Brendan’s heart was trying to improve the blood supply by beating harder and faster, causing symptoms of angina.
Brendan’s doctor recommended that Brendan have an operation to fit his heart with two stents. The stents would stop the coronary arteries from narrowing and relieve Brendan’s angina symptoms.
Brendan called his insurance adviser and asked if his condition and surgery were covered under his trauma insurance policy.
Brendan’s insurance adviser confirmed that his condition and operation were covered under the policy. Brendan’s insurance adviser also told Brendan that the sum insured under his trauma policy was $50,000.
Brendan filed a claim with his insurer in April 2015. Brendan’s insurer accepted Brendan’s claim and Brendan was paid $12,500 in May 2015.
Complaint
Brendan was unhappy that he only received $12,500. Brendan said he had relied upon his insurance adviser’s advice that the sum insured for his trauma policy was $50,000 and had arranged for renovations on his house using his expected $50,000 insurance pay out.
Brendan complained that he had been misled and wanted his insurance adviser to make up the $37,500 difference and to apologise for misleading him.
Brendan and his insurance adviser were unable to resolve the complaint and Brendan came to FSCL in June 2015.
Review
We asked Brendan’s insurance adviser for its file and the insurance policy wordings.
We confirmed the sum insured under Brendan’s trauma policy was $50,000; however we also found that Brendan’s insurer had acted correctly under the policy in paying Brendan $12,500.
Brendan’s policy specified that in the case of angina that required surgery, the maximum benefit was a payment of 25% of the total sum insured. This was the $12,500 that Brendan was paid.
As a result of the policy wording, we found there was no financial loss suffered by Brendan from the actions of his insurance adviser. However, we felt the financial adviser could have been clearer with Brendan when it told him the sum insured value and explained to him that his policy could pay out less than the total sum insured for some conditions. Unfortunately, Brendan had relied on the insurance adviser’s erroneous advice when committing to expensive house renovations.
Outcome
Brendan and the insurance adviser were able to reach a confidential settlement with FSCL’s assistance. Brendan received $4,000 in compensation.
Our insight
We help complainants and FSCL participants to resolve complaints and many complaints can be resolved by agreement promptly and easily, without the need for a formal written decision.
