While still in China, Xiu Mei was successfully treated for appendicitis with antibiotics. Over a year later Xiu Mei travelled to New Zealand to study. Xiu Mei arranged travel insurance, and during the online application process was asked whether she had received treatment for any sickness or injury in the last 6 months. Xiu Mei correctly answered ‘no’ to this question.
About six months later Xiu Mei experienced abdominal pain, went to the hospital, and was diagnosed with appendicitis. Xiu Mei’s doctor operated, removing her appendix.
Xiu Mei submitted an insurance claim to the insurer for the costs of her surgery. Xiu Mei’s claim was declined on the grounds that her appendicitis was a pre-existing medical condition.
Xiu Mei complained to FSCL.
Xiu Mei’s view
Xiu Mei considered her claim should be covered because Xiu Mei’s doctor advised that her recent appendicitis was unrelated to the appendicitis she experienced in China. Xiu Mei had completely recovered from the previous appendicitis, and her current condition was a distinctly separate occurrence.
We could understand that, from Xiu Mei and her doctor’s perspective, the two episodes of appendicitis were completely separate. Xiu Mei had successfully recovered from the first episode, after being treated with antibiotics, and did not expect to experience appendicitis again.
However, in our view, the insurer was entitled to decline Xiu Mei’s claim because the policy defined a pre-existing condition as any medical condition for which Xiu Mei had sought medical attention prior to the start date of the policy. There was no dispute that Xiu Mei had sought medical attention for appendicitis before the start date of her policy. Xiu Mei’s claim was therefore excluded from cover under the policy exclusion for a pre-existing medical condition.
Xiu Mei was disappointed with our decision, but as she did not have any new evidence to allow us to reach a different conclusion we discontinued our investigation into her complaint.
Key insight for consumers
A medical definition and a policy definition of a pre-existing medical condition may differ, but because an insurer’s obligation to pay a claim is found in the insurance policy, the policy definition has to be applied.
Consumers should be aware that insurance policies’ definitions of pre-existing medical conditions are drawn very widely.