How a pre-existing medical condition is defined

A pre-existing condition you do not know about 

Jocelyn and her husband booked an overseas trip in December 2012 to take place six months later.  Jocelyn arranged a travel insurance policy with All Claims Covered through her travel agent.  Jocelyn had earlier consulted her doctor about ongoing symptoms which she thought had been caused by food poisoning but did not disclose any pre-existing medical conditions in the policy application. 

In June 2013, Jocelyn cancelled the trip because of ongoing treatment for pancreatitis which had been diagnosed after she had made the bookings. Jocelyn claimed under the travel policy for cancellation costs. All Claims Covered accepted the claim in part: it agreed to pay the cancellation cost incurred by Jocelyn’s husband but declined to pay Jocelyn cancellation cost because the trip was cancelled due to a pre-existing medical condition. 

 

The claim 

Jocelyn believed All Claims Covered’s decision to decline her claim was unfair because when she arranged the policy she was unaware of the severity of the symptoms she was then suffering.  She did not know about the possible diagnosis of pancreatitis until January 2013. 

 

All Claims Covered’s position 

All Claims Covered argued that pancreatitis was a pre-existing medical condition as that term is defined in the travel policy.  A pre-existing medical condition included any medical condition with signs or symptoms for which specialist opinion has been arranged.   Jocelyn’s medical records disclosed that she had received medical treatment in October, November and December 2012 for symptoms that led to the diagnosis in January of pancreatitis. The specialist appointment was arranged before Jocelyn arranged the insurance policy. 

 

FSCL’s findings and recommendation 

Our role was to determine whether All Claims Covered had relied on its policy wording fairly when it declined Jocelyn’s claim for cancellation costs incurred. 

When Jocelyn booked the travel and arranged insurance cover, the travel agent asked about pre-existing medical conditions.  Jocelyn mentioned her recent medical symptoms which she thought came from food poisoning, and said she had no pre-existing medical condition to declare in the application. 

We accepted that the pancreatitis diagnosis was a circumstance outside Jocelyn’s control and that she was unaware of her condition when she made the travel bookings.  Therefore we had to be satisfied that All Claims Covered had proved that the trip cancellation arose from signs or symptoms that Jocelyn was aware of when she booked the trip, but which were awaiting a specialist opinion.  For All Claims Covered to decline the claim it did not have to prove that Jocelyn knew she had or could possibly have pancreatitis.  It only needed to prove that she was aware of signs or symptoms which required a further specialist opinion.  Jocelyn could not recall exactly when her GP confirmed the specialist appointment but the GP’s notes confirmed he had told her before she made the travel arrangements. 

On the available evidence it seemed likely that if Jocelyn had declared her symptoms on the application, All Claims Covered would not have provided any cover for Jocelyn’s symptoms pending the specialist appointment already arranged. Therefore ACCL was entitled to decline her claim under the policy terms.  We could not uphold Jocelyn’s complaint and recommended that it be withdrawn.