Sairah was a student at the University of Canterbury and had a student travel policy with an insurance company.
In May 2016, Sairah started experiencing tooth pain and visited a New Zealand dentist. Her dentist recommended extensive dental treatment including a number of root canals.
In November 2016, Sairah decided to travel from New Zealand to Pakistan (her home country) to receive the recommended dental treatment and recover, because the cost would be significantly less than receiving the same treatment in New Zealand.
Sairah returned to New Zealand in January 2017.
In late January 2017, Sairah made a claim for her return flight from Pakistan to New Zealand which cost $700. The insurance company declined Sairah’s claim because it considered there was no cover under the student policy for the circumstances of her claim. Sairah did not claim for the dental treatment she received, however, she hoped the insurance company would reimburse her for her flight back to New Zealand.
While Sairah’s student policy did include cover for repatriation, the insurance company would only pay for her to return home in certain circumstances which included:
(a) having to return to her country of origin during the Period of Insurance due to the Unforeseen death, Serious Injury or Serious Sickness of a Relative or travelling companion, provided that such a person is under 76 years of age.
(b) him suffering an Injury or Sickness during the Period of Insurance.
(c) any other unforeseen circumstance not covered elsewhere in the Policy which is outside her control other than those circumstances described in (a) and (b) above or specifically described elsewhere in the Policy.
Sairah’s claim
Sairah believed her claim should have been covered under subsection (b) because, as part of her dental treatment, she required treatment for gum disease and the policy defined ‘Sickness’ as any illness or diseases.
Review
General exclusions
Sairah’s policy included general policy exclusions which applied to all policy sections:
We will not pay under any section of the Policy for any claim arising directly or indirectly out of:
14. Travel undertaken for the purpose of receiving medical treatment (whether or not this was the sole purpose for such travel) unless agreed to by us prior to the departure date for the travel.
Insurer’s position
The insurance company’s position was that even if Sairah had contracted the gum disease prior to her trip to Pakistan, it would not have agreed to pay for any costs associated with travelling to Pakistan for dental treatment.
This is because the policy only covered emergency dental work up to a maximum of $500.
Further, the policy specified that there would be no cover for periodontal (gum disease), root canals, or any work resulting from lack of regular dental maintenance and/or hygiene. As such, had Sairah submitted a claim to receive her dental treatment in New Zealand, the claim would also have been declined by the insurance company.
Sairah complained to FSCL.
Outcome
We agreed with the insurance company’s policy interpretation.
If there was no cover under her policy for Sairah to receive dental treatment in New Zealand, then there was also no cover for her to receive dental treatment in Pakistan or any costs associated with receiving treatment in Pakistan, including her return flight from Pakistan to New Zealand.
We recommended that Sairah discontinue her complaint.
