Claire was an overseas student, studying in New Zealand. She experienced headaches and problems with nasal breathing which she saw GPs and specialists about. She was diagnosed with allergies and a deviated septum.
Claire claimed the costs of her appointments, medications, a scan, and tests, under her student travel insurance policy. The insurer paid some of the claims but then realised they related to a pre-existing medical condition, which Claire had not disclosed. The insurer declined to pay the remainder of Claire’s claims, which totalled $600. The insurer also declined pre-approval for surgery on her septum.
Claire’s policy excluded cover for pre-existing medical conditions which had not been disclosed to the insurer and accepted for cover. Medical records the insurer obtained from the various doctors Claire had seen recorded that she had a history of sinus issues, facial pain, headaches, and a deviated septum.
Claire complained to FSCL because she did not agree her condition was pre-existing.
Claire said her condition was not pre-existing because her symptoms started when she arrived in New Zealand. Claire also said the insurer had misled her. She would not have made one of her specialist appointments if she had known the cost was not covered.
The insurer maintained that Claire’s claims related to a pre-existing medical condition.
It was reasonable for the insurer to believe, based on the medical records they had, that Claire’s condition was pre-existing. The policy defined pre-existing condition as including symptoms. While Claire had not been diagnosed with allergies before coming to New Zealand, she had symptoms associated with them. Claire also knew she had a deviated septum.
We also concluded that the insurer had not misled Claire. The insurer did not say they would continue to pay related claims. Claire had concluded this herself.
Claire did not agree with our view: she maintained that her condition was not pre-existing.
In the interests of resolving the complaint, the insurer decided to pay the outstanding claims which totalled $600, but they made it clear they would not pay any further related claims. Claire accepted this in full settlement of her complaint.
Insights for consumers
It is important to disclose all pre-existing medical conditions when taking out medical or travel insurance. The meaning of pre-existing medical condition is usually defined in the policy wording, and it usually includes signs and symptoms of a condition.
If you have not disclosed all pre-existing medical conditions, a claim will likely be declined. The insurer may also void the policy altogether.