Ataahua had private hospital cover through her medical insurer. Unfortunately, Ataahua’s insurer forgot to tell her that her cover lapsed in 2017, when she turned 64. Ataahua carried on paying her insurance premiums for two years and incurred private medical care expenses on the belief that she had medical cover.
The insurer refunded Ataahua $2,178 in premiums with interest. It also agreed to assess any medical claims from Ataahua during the period she was paying premiums.
Dispute
Ataahua did not accept the insurer’s offer to settle the complaint and complained to FSCL. In resolution, she asked the insurer to provide her with cover for the rest of the year and to pay all her private medical bills. The insurer did not agree to provide Penny with cover or pay any further compensation.
Review
We encouraged Ataahua to submit her medical claims to the insurer. The insurer assessed Ataahua’s claims and said her policy did not cover her diagnosis of “dilated oesophagus secondary to motility disorder.” This was because her medical policy only covered her for four specific conditions (heart attack, coronary artery disease, stroke and cancer).
We explained to Ataahua that whether or not she still had cover with the insurer, she would not be covered for claims relating to her current diagnosis. The insurer had tried to resolve Ataahua’s complaint by giving her the benefit of cover and considering her insurance claims. It has also refunded Ataahua her premiums with interest.
Resolution
Ataahua noted there was not much more she could do and thanked us for our support. On that basis, we closed Ataahua’s complaint.
Insights
An insurance policy may have an age restriction; therefore, it is important to read the terms of each individual policy.
Insurers are expected to provide clients with adequate notice of termination of a policy so that the client has the opportunity to source replacement cover, or make other arrangements.
