Trevor purchased cancer disability insurance cover from a door to door insurance sales person in the 1970’s. Recently Trevor developed a skin cancer that spread to his saliva gland requiring facial surgery and radiotherapy, leaving him with a disfigured face and some discomfort.
Trevor lodged an insurance claim with his insurer. The insurer accepted part of the claim, paying Trevor $485.70 for the time Trevor was either totally or partially disabled while he recovered from the surgery.
Trevor considered the insurer had made a mistake, because it did not pay him the lump sum benefit of $30,000 for the removal of a cancer. Trevor also asked whether his policy might cover the distortion to his face.
The insurer’s response
The insurer explained to Trevor the policy definition of ‘cancer’ did not include skin cancer, unless the cancer had spread to another part of the body. The insurer asked Trevor’s doctor whether Trevor’s cancer could be considered a ‘skin cancer’ and whether the cancer had spread. Trevor’s doctor confirmed the cancer was a skin cancer, but had not spread to any other parts of Trevor’s body. The insurer confirmed its decision to decline the claim.
The insurer also explained its view that although there was cover under another policy for permanent facial disfigurement, the disfigurement must be caused by violent, external and visible means, and specifically excludes sickness. The insurer did not accept Trevor’s facial disfigurement was covered by the policy.
Trevor’s view
Trevor did not accept the insurer’s decision, saying the cancer had spread from the skin to his salvia gland, requiring surgery and radiotherapy. Trevor considered the claim should be covered by the policy, and complained to FSCL.
Review
We looked at the wording of the policy, and the expert medical evidence provided by Trevor’s doctor, and agreed that Trevor’s claim was not covered under his cancer disability policy.
We explained to Trevor that his insurer was only obliged to pay what is covered under the policy. While the policy provided cover for cancer, it excluded cover for skin cancer, unless that cancer has spread to other organs.
We understood Trevor’s claim that the skin cancer had spread to his saliva gland but Trevor’s doctor’s advice was clear, the skin cancer was confined to the primary site, with no evidence that it had spread. We had to accept the doctor’s expert advice. It followed that the policy requirements were not met.
Outcome
Trevor reluctantly accepted our view, and discontinued his complaint.
Our insight
All insurance policies contain limitations. An insurer’s liability is limited to the policy wording. While we could understand Trevor’s disappointment that after many years of paying for the policy he felt let down, we could not find the insurer was liable to accept the claim.
