In July Tyler discovered a lump in her breast, she went for a scan in August and, in September, was told that it was benign, but that it should probably be removed. Tyler scheduled the operation for November.
In October Tyler and her partner booked flights to travel to Australia in February for a friend’s wedding
Tyler became very busy at work, so went to her specialist and rescheduled the operation for January.
Following the surgery in January, Tyler was diagnosed with breast cancer and required immediate treatment. The follow-up treatment was scheduled for the same time as the planned trip and Tyler and her partner cancelled the flights.
Tyler and her partner were relying on complimentary credit card travel insurance for the trip. When they cancelled the trip, they submitted a claim, but the insurer declined it on the grounds that the loss was caused by a pre-existing medical condition.
Dispute
Tyler said this was very unfair. Although she knew about the lump, Tyler had no idea how serious it was. Tyler submitted a statement from her surgeon confirming that the cancer diagnosis came as a complete shock that neither he nor Tyler were expecting.
The insurer responded, referring to the policy wording which referred to any “sickness, injury or condition which has occurred or which you have been aware of, or for which treatment, medication or medical attention has been sought…”. Although Tyler did not know she had cancer, she knew that she had a sickness which required treatment, which she had not disclosed. The insurer maintained its decision to decline the claim.
Review
We agreed the insurer was entitled to decline the claim. We explained that the phrase ‘pre-existing medical condition’ took on a special meaning within the context of the insurance policy. A pre-existing medical condition is defined to include any sickness, which was defined as any illness or disease, including symptoms.
It was our view that although Tyler did not know she had cancer, she knew she had symptoms that could indicate cancer and, at the very least, required a surgical procedure. The pathologist’s report following the biopsy diagnosed a fibroadenoma and an atypical lobular hyperplasia (B3). The surgeon’s notes from the appointment in October, when Tyler delayed the surgery, indicated that although he did not know Tyler had cancer, he knew enough to be concerned.
Resolution
Although Tyler was disappointed with our decision, she was prepared to accept it and we discontinued our investigation.
Insights for consumers
Tyler asked what more she could have done to avoid having the claim declined. We advised that Tyler could have called the insurer to see whether it was prepared to cover the pre-existing medical condition. This complaint highlights a problem with complimentary credit card insurance. Because there is no application process for the policy, cover is confirmed only after a claim is lodged, and there is no opportunity to prompt the insured to disclose a pre-existing medical condition.
