The claim
Adrian was travelling with his family in the United States in January 2013. He developed a deep vein thrombosis (“DVT”), which resulted in major disruptions to his family’s holiday resulting in financial losses of around $20,000.
Adrian’s travel insurance company declined Adrian’s claim because it said his loss arose from a pre-existing medical condition and therefore, cover was excluded under the insurance policy.
Adrian had previously been diagnosed with a DVT and pulmonary embolus (“PE”) in 2006 following a leg fracture. He said this was treated and resolved and he was cleared of the condition in 2007.
Adrian’s GP had referred him to a specialist in May 2012 as Adrian wanted to know whether he needed to continue with the compression stockings he had been wearing to minimise a recurrence of the DVT and PE. Adrian also suffered a blood clot following knee surgery in July 2012. In Adrian’s view, because these issues resolved, he did not have a pre-existing medical condition when he purchased the insurance policy and when he got on the plane.
The insurance policy
We reviewed the insurance policy wording and in particular, a general exclusion clause which said that the insurance company would not pay for a claim under any circumstances if it arose directly or indirectly from, was in any way connected with or was related or associated with, any pre-existing medical condition.
‘Pre-existing medical condition’ was specifically and comprehensively defined under the policy. Part of the definition said that a pre-existing medical condition included any medical or dental condition or symptom in the past 2 years for which the insured had been in hospital, the emergency department or day surgery, or for which the insured had been prescribed a new medication or had a change to their medication regime.
Medical evidence
Adrian had been on no medications specifically for DVT when he first met with the specialist in May 2012. However, after Adrian developed the clot following the surgery in July 2012 he was given the drug clexane and remained on it. Clexane is a drug used specifically to prevent and treat DVT.
We did not accept Adrian’s argument that because he was not suffering a DVT at the time he purchased the insurance policy or when he got on the plane, he was not suffering a pre-existing medical condition. The medical evidence indicated to us that Adrian was suffering a medical symptom of DVT in the 2 years prior to his trip to the United States, for which he had a change to his medication regime. Adrian’s history of blood clots clearly fitted within the insurance policy’s definition of a pre-existing medical condition.
Arose from, connected with, related to, associated with?
We also needed to look at whether Adrian’s claim arose from, was in any way connected with or was related to, or associated with, his pre-existing medical condition.
We noted that Adrian’s specialist had examined him further at the end of November 2012 (only a matter of weeks before he was to depart on his trip), and had prescribed Adrian medication and gave him injections to prevent him developing a DVT during the long haul flights to the United States.
Further, the insurance company’s chief medical officer provided a report which concluded there was a clear risk that Adrian would suffer a recurrence of DVT as a result of flying long haul. Later, Adrian’s specialist said he was being overly cautious in prescribing the preventative medication and said that Adrian’s previous episodes of DVT did not put him at higher risk of developing another DVT. We found the specialist’s later comments difficult to reconcile with the fact that he had prescribed Adrian the preventative medication. We also noted that the connection between long haul flying and the risk of developing DVT is a well known general fact.
In light of the risk we found that Adrian’s claim was at the very least, connected with his pre-existing medical condition.
Further, we noted that Adrian clearly knew about his history of blood clots and was concerned enough about this history to mention his upcoming trip to America to his specialist. We found this difficult to reconcile with the fact that Adrian argued that his previous blood clot episodes had resolved and that he did not have a pre-existing medical condition. We also noted that Adrian appeared to know about the need to disclose information about his medical history as he had disclosed a pre-existing back problem and a knee ligament injury when he applied for insurance cover.
We issued a formal Recommendation that Adrian’s claim and complaint was not upheld.
