Lobster dinner makes a crabby traveller
While aboard her cruise, Mary-Ann cracked a tooth on a hard piece of shell while enjoying her lobster dinner. She was unable to receive dental treatment on the ship and it caused her considerable pain for the remainder of the holiday especially while eating.
On return to New Zealand, Mary-Ann made an appointment with her dentist and underwent a root canal procedure and had a crown put on the damaged tooth. The procedure and crown cost $1,900 and Mary-Ann claimed for her dental work under her travel insurance policy with Adventurers Assured.
Adventurers Assured declined Mary-Ann’s claim on the grounds the incident was not ‘violent’ and therefore could not be classified as an injury. A clause in the policy stated injury caused only by “violent, accidental, external and visible means” was a covered injury under the policy. Adventurers Assured believed that this exclusion was applicable to Mary-Ann.
The policy also stated that it would not cover dental expenses incurred in Mary-Ann’s country of origin. Further, it was explicitly stated in the policy that claims that arose from root canals would not be paid.
The complaint
Mary-Ann complained that her claim had been declined and that her accident should not be excluded under the policy.
FSCL’s involvement
We reviewed Mary-Ann’s claim and found, that in the circumstances, the chewing of a piece of lobster shell should be considered an injury because the jaw exerts a force in the act of chewing that could be reasonably interpreted as being ‘violent’. Applying contra proferentum, the legal rule that says where there is more than one reasonably possible interpretation the one most favourable to the insured should be preferred, we found that Mary-Ann claim succeeded on this point.
We also considered that the proximate cause of Mary-Ann’s injury was accidental, despite her carrying out an intentional act of eating lobster because the injury was an unforeseen, unexpected and unintended mishap that had intervened to produce the injury. In our view the injury satisfied the policy.
Outcome
We found that Mary-Ann’s claim was nonetheless excluded because the dental work claimed was performed in her ‘country of origin’. New Zealand was Mary-Ann’s principal residence prior to applying for her travel insurance cover and as Mary-Ann returned to New Zealand to have the dental work undertaken it was excluded. Mary-Ann’s claim would likely be covered under the ACC legislation as an accidental injury but because she received treatment at home after her holiday it was excluded under her travel insurance policy.
Lesson
The wording of your insurance policy is carefully drafted to cover specific events and should be read carefully. If you do not understand how a clause in your policy operates or what it means you should seek clarification from your insurer before travelling.
In responding to injury, most travel insurance policies allow for immediate treatment of serious injuries and will provide for your return home. Typically, your travel insurance will not respond to medical treatment provided or given in New Zealand that would normally be covered be ACC.
