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Insurance claim for tooth knocked out

Eric heads to Thailand for a holiday

Eric went on holiday to Thailand in 2014. While out playing golf, Eric bit down on a sandwich hitting a chicken bone, and his tooth was knocked out. Eric went to a dentist in Thailand for treatment and received a root canal.

Eric continued with the remainder of his holiday. When he returned to New Zealand he made a claim to his travel insurance company, Whistle Insurance (“Whistle”) for the costs of the dental treatment. The claim was for $1,532.40 NZD.

Whistle declined Eric’s claim.


But which tooth?

Before we could begin our investigation as to whether Whistle was entitled to decline Eric’s claim we had to establish which tooth Eric received treatment for.

The summary of work from the dentist in Thailand, Bright Smile, stated:

(Eric) “…came to my office with severe pain on tooth number 22. The patient had a crown on the tooth and fell off before he came. After examination I found that its root was cracked and cannot be saved and also needs immediate treatment.”

Eric’s dental records from his New Zealand dentist, Kiwi Teeth, showed that in August 2011 Eric’s tooth 22 had a crown inlay fitted as a temporary measure. Kiwi Teeth’s records also showed that in August 2011 it sent a request to ACC seeking approval for further dental treatment for Eric’s tooth 22. ACC had approved this further work.

Eric acknowledged that he did receive dental treatment for tooth 22 at Kiwi Teeth in August 2011. He said Kiwi Teeth put a temporary cap on his tooth 22 and it lasted well so he did not bother going back. However, Eric said that it was not tooth 22 which he received dental treatment for in Thailand. Tooth 22 is the tooth on the left of the two front teeth. Eric said it was his top left front middle tooth, tooth 21, which the dentist in Thailand extracted the root canal from. Eric believed that the Thai dentist must have made an error recording which tooth needed to be extracted.

The tooth that Eric said fell out in Thailand was sent to Kiwi Teeth to confirm whether the tooth was tooth 22 or tooth 21. Kiwi Teeth responded and said the tooth was more likely to be tooth 22 than tooth 21.

In balancing the evidence, we decided that the treatment recorded by the Thai dentist was, more likely than not, correct. We placed weight on Kiwi Teeth’s advice that the tooth was more likely tooth 22, not tooth 21.


Was Whistle entitled to decline Eric’s claim for the treatment of tooth 22?

In our view, Eric was not covered under the policy for treatment carried out in Thailand on tooth 22.

We found that Eric did not satisfy the insuring clause of the policy. To satisfy the insuring clause, Eric had to have suffered an “injury”. However, Eric did not suffer an “injury” because the “injury” resulted from a pre-existing medical condition, a damaged tooth with a temporary crown.  In 2011 it was recommended that tooth 22 be extracted and Eric did not proceed with that recommended treatment. All claims arising from a pre-existing medical condition were excluded under the policy.

We recommended that Eric withdrew his complaint.