Tim booked a trip to South Africa. When applying for travel insurance, Tim disclosed his pre-existing medical conditions relating to his heart and discussed the possibility of paying a higher premium in order to have these conditions covered. Because he had not experienced any issues relating to his bypass or aneurysm in recent history, Tim decided to accept a quote which didn’t have extra cover. This meant issues relating to his bypass and aneurysm were not covered by the policy.
Five days before his trip, on 1 April, Tim suffered prolonged cramp in his leg. After seeing a doctor, it was determined that the ‘cramp’ was actually a blood clot and Tim had to have an operation. Tim had surgery for the clot on 13 April and was discharged from hospital on 19 April. Because Tim could no longer travel, he claimed for the cancellation costs on his travel insurance. The non-refundable costs associated with his trip amounted to $8,900.
Tim’s application for cover was declined by the insurer on the basis of a pre-existing medical condition. The insurer believed that Tim’s current ‘injury’ was related to his declared pre-existing medical conditions. Moreover, the insurer asserted that during the medical assessment Tim had answered a question, which specifically asked about the condition which caused the blood clot ((peripheral vascular disease) PVD)), negatively when he should have answered positively.
Tim believed that, because his heart specialist had told him that the leg issue had no connection with his previous health issues, the clot was not a ‘pre-existing medical condition.’
Tim complained to FSCL.
The insurance policy
Tim’s insurance policy stated it would not pay claims relating directly or indirectly from pre-existing medical conditions. The policy defined PEMC as any physical defect, infirmity, existing or recurring illness, injury or disability of which you are aware of.
Tim said that the condition which caused the clot was unrelated to his pre-existing conditions and the insurer had mistakenly connected the two occurrences.
Tim argued that he couldn’t have known that his leg issue was ‘PVD’ because he was not a doctor. When he answered negatively to the question “have you ever suffered PVD?” he honestly believed that he had not suffered from it before. Furthermore, Tim relied on his heart specialist’s letter which asserted that there was no connection between his previous bypass and the current blood clot. Tim thought that this should have been enough for the insurer to accept his claim.
The insurer’s view
The insurer declined Tim’s claim because, during his medical assessment, he had mistakenly answered a question regarding whether he experienced PVD negatively when he had in fact.
During the medical assessment Tim declared his abdominal aortic aneurysm because it was a condition relating to his heart. As a result, the assessor asked whether he had ever experienced any poor blood supply in his legs, because this was a related condition and there is a known connection between the two. The insurer argued that because the condition was specifically asked about during the assessment, the condition should have been declared.
The insurer had to decide whether Tim’s clot arose from a pre-existing medical condition. The emergency medicine specialist who the insurer consulted stated there was a relationship between Tim’s prior history and the current medical problem. It would be reasonable to consider this event as part of Tim’s underlying vascular disease.
The specialist’s report stated Tim had PVD affecting the leg which required surgery before obtaining travel insurance. While the ‘acute occlusion’ of the leg was not present at policy inception, Tim had multiple risk factors for thrombotic disease and It would have been reasonable for the insurer to expect Tim to declare his extensive history of vascular disease.
Tim had received a ‘femorofemoral crossover bypass graft’ in the past. The purpose of this was to improve blood supply to Tim’s legs and relieve his symptoms. As a result, it was clear that the PVD should have been declared and Tim should have answered yes to the question surrounding poor blood supply to the legs.
PVD was the cause of Tim’s cancellation. He had received treatment for poor blood supply in the past and failed to disclose this. Even if Tim had taken the extra cover available he had failed to disclose the poor blood supply which would, under the policy, be considered a PEMC.
This condition should have been declared when Tim applied for insurance in February 2017. Tim was specifically asked by the medical assessor if he had ever experienced any poor bloody supply (or PVD) and answered “no.” Tim’s recorded conversation with the medical assessor made it clear that Tim agreed he understood his disclosure duties. The recording suggested that obtaining a list of medical conditions from his doctor may be helpful.
Tim had received treatment for PVD in the past. This was, according to the policy, a PEMC. This meant Tim’s claim was excluded under the policy because he had failed to declare a PEMC. Furthermore, Tim was asked specifically about PVD and answered falsely. Although he didn’t do so intentionally, he had a duty of disclosure and had failed to disclose a condition that was material to the insurer.
Key insight for consumers
Medical assessments comprise part of your insurance policy. Take care when completing them because false or incomplete answers may preclude coverage at a later date. The answers given during medical assessments (whether they be by phone or in person) can have major subsequent effects on claims.