Maja is an overseas student studying in New Zealand. She arranged travel insurance to cover her medical costs while in New Zealand. When Maja became pregnant, while in New Zealand, her medical expenses were covered by government funding. However, after her baby was born Maja’s GP referred her to the physiotherapy clinic for treatment of a muscle strain she suffered during labour.
Maja believed the physio appointment would be covered by government funding and was surprised when she received an invoice from the hospital. When Maja queried the invoice, she was advised that government funding only covered medical treatment up to six weeks after the birth. Maja’s physio appointment was in the seventh week and so not covered by government funding.
Maja submitted the invoice to her insurer. The insurer declined the claim because a statement from the physiotherapist referred to a muscle strain during labour and the policy excluded cover for any loss arising directly or indirectly from pregnancy or childbirth.
Maja felt this decision was unfair and complained to FSCL.
Dispute
Maja understood that her travel insurance would cover her for any medical treatment in New Zealand that was not covered by the New Zealand government. Maja had an invoice from the hospital and believed it was covered by the policy.
Maja’s insurer maintained their view that they were entitled to decline the claim relying on the policy exclusion for loss arising directly or indirectly from pregnancy or childbirth.
Review
After reviewing the policy, we explained to Maja that the insurer was entitled to decline the claim. Although the policy covered Maja’s medical expenses, before accepting the claim, the insurer was entitled to consider whether any policy exclusions applied. The policy wording was clear, and the description of Maja’s medical treatment referred to an injury occurring during childbirth.
However, Maja’s GP had referred her to the hospital physio four weeks after birth. It appeared to us that it was the delay in Maja receiving an appointment that pushed her medical expenses outside the six weeks following birth. We suggested to Maja that she contact the hospital administrator again and ask them to reconsider the invoice on this basis.
Resolution
Maja accepted our view and discontinued her complaint about the insurer.
Insights for consumers
Although insurance policies usually state that the insurer will cover necessary and reasonable medical expenses, before accepting the claim, the insurer is entitled to consider whether any policy exclusions apply. An exclusion for loss arising directly or indirectly from pregnancy and childbirth is a standard policy exclusion.
