Biting off more than one can chew

Pam and Jim were travelling in Singapore when Jim bit on something hard and injured his upper molar. Jim couldn’t eat, had severe tooth pain, sore gums and discomfort when wearing his dentures. Jim visited a dentist for the pain and the dentist extracted his molar. The dentist proposed a plan to restore two implants and a bridge restoration for three teeth. Pam phoned the travel insurance company and spoke to Teddy before proceeding with the treatment.

Upon returning to New Zealand, Pam claimed for the cost of Jim’s dental treatment in Singapore.

The insurer agreed to pay the portion of the claim that was for an emergency extraction of Jim’s injured upper molar (minus the policy excess). It declined the rest of Jim’s dental treatment which had cost $22,000. This is because, while Pam and Jim’s travel insurance policy had cover for “emergency dental treatment” to relieve sudden and acute pain to sound natural teeth, it excluded cover for dental treatment relating to dentures, dental implants, or dental bridges.

Pam was unhappy with the insurer’s decision and laid a complaint with FSCL. She complained that if not for Teddy giving her the “go ahead”, she and Jim would have returned to New Zealand. Pa, also complained it was unfair the insurer had applied the excess three times to each of her claims when all three claims had been made under one travel insurance policy.  

 

Review

Upon review, we agreed with the insurer.

The policy wording was clear. While it included cover for emergency dental treatment, it did not include subsequent denture-related work.  While the treatment was as a result of the tooth extraction, it was not emergency treatment.

We listened to the phone recordings where Teddy read out the policy section to Pam about the maximum cover available for emergency dental treatment. Teddy did not confirm there would be cover beyond the maximum policy benefit. Teddy invited Pam to submit her claim for consideration. We did not think it was reasonable for Pam to assume the insurer had guaranteed payment for all future non-emergency dental treatment in clear contravention of the policy wording.

Had the couple returned to New Zealand, Jim would have always needed to undertake the treatment, albeit at a lower cost.

We further agreed that, an excess applied to each separate event giving rise to a claim. The insurer was correct in applying the excess to each of Pam’s claims.

 

Outcome

We did not uphold the complaint. We issued our final recommendation noting Jim’s injury was accidental and fell within emergency dental expenses as it was related to his molar and treated by a dentist. Pam could not claim Jim’s dental costs that were expressly excluded under the travel insurance policy. Pam had neither presented a treatment plan to the insurer nor sought the insurer’s agreement to over the treatment cost above and beyond the policy benefit.

 

Our insights

An insured is obliged to read and understand their policy wording. An insured should be careful to ensure they keep their insurer informed and have their agreement before undertaking expensive medical and dental treatment overseas.