The propensity to develop infections can mean you have a ‘pre-existing medical condition’

The medical declarations and the endorsement

In late December 2014, Claire purchased travel insurance to cover her for a European cruise for three weeks in July 2015. On 5 January 2015, Claire completed a medical declaration for her travel insurance but did not pay an additional health premium at the time because she was unsure whether her friend and travelling companion Agatha would be able to go on the cruise.

Claire undertook a further medical declaration in early April 2015 (the January assessment having expired). The insurer endorsed Claire’s policy with the following exclusion clause:

“We will not pay any claims arising directly or indirectly from, related to or associated with:

–        Condition for which urostomy was performed.”

In simple terms, a urostomy is an operation to create an opening for the removal and collection of urine from the body. Claire had undergone a urostomy operation following the removal of her bladder after she suffered from bladder cancer.

Claire was unconcerned by the endorsement. She considered it would not affect her because the urostomy had been performed because of her bladder cancer. Because she no longer had a bladder, Claire considered there was no risk of her having a medical issue to do with her bladder.

Claire’s UTI

In July 2015 Claire and Agatha started their trip. Most unfortunately, a day into the cruise, Claire had to disembark the cruise ship because she was suffering from a urinary tract infection (UTI). Claire left the ship upon the advice of the doctors onboard and was taken to hospital in Belgium.

Claire remained in hospital for around 2 weeks by which time it was too late for her to re-join the cruise. Claire then travelled to London so she could make her return flight to New Zealand as planned.

Claire’s claim

Claire made a claim to her insurer for the costs of the overseas medical treatment, the cost of the curtailed cruise, and additional expenses she incurred (approximately $8,000). The insurer declined Claire’s claim because it considered the UTI she suffered was linked to her urostomy.

The insurer’s medical team also reviewed Claire’s medical history which showed Claire had been treated for a number of UTIs in the previous five years. In particular, Claire had been treated for a UTI in November 2014, prior to her purchasing the travel insurance policy in December 2014. Claire also had a UTI in March 2015, (after purchasing the policy but prior to her second medical declaration). The insurer said if Claire wanted to be covered for her UTIs, she should have declared the condition.

The insurer also considered that because Claire had had a urostomy, along with her being post-menopausal, and having a history of diabetes and obesity, she was at higher risk of developing UTIs. The insurer said that in addition to declining the claim under the urostomy exclusion, it could decline her claim on the basis of its general pre-existing medical condition (PEMC) exclusion clause. The insurer considered Claire’s propensity for developing UTIs met the policy definition of a PEMC.

Claire complained to FSCL.

Claire’s view

Claire said the insurer’s decision was unfair, because she considered the UTI she suffered in Europe was not linked to her urostomy operation. Claire also said a UTI was not a PEMC. Claire argued that when a person gets a UTI, it clears up with antibiotics meaning the UTI could no longer be ‘pre-existing’.

FSCL’s review

In plain wording, the urostomy exclusion excluded any claim arising directly or indirectly from bladder cancer (bladder cancer being the reason the urostomy was performed). We had to decide whether Claire’s claim arose directly or indirectly from bladder cancer.

We first looked at the medical evidence. The insurer’s doctors said Claire was at higher risk of developing UTIs than other women her age, although it could not be said that Claire’s urostomy definitely caused her UTI in Europe. Claire’s doctor said there was nothing in Claire’s medical history to indicate her urostomy was associated with her UTIs.

We preferred the insurer’s doctor’s evidence and said Claire’s urostomy was one of the factors making her more at risk of developing a UTI. It was more likely than not that Claire’s urostomy was a causative factor in her developing the UTI in Europe (in conjunction with her other risk factors).   

The insurer correctly relied on the urostomy exclusion because Claire’s claim arose indirectly from her having had bladder cancer. The chain of events was that:

1)               Claire had bladder cancer.

2)               Claire’s bladder was removed.

3)               Claire underwent the urostomy.

4)               The urostomy was more likely than not a factor in her having the UTI in Europe.

The PEMC exclusion clause

We also agreed with the insurer that the claim could be declined under the PEMC exclusion clause. The definition of a PEMC included ‘a medical condition that had been investigated or treated by a medical professional at any time in the past prior to policy purchase’. We said that the UTIs Claire had suffered in the past met that definition.

Essentially, Claire was more susceptible to developing UTIs because of the combination of factors in her medical history, including having had several UTIs prior to the UTI she suffered from in Europe. 

Outcome

Although Claire considered the outcome to be unfair she decided to discontinue her complaint.

Our insight

Exclusions in travel insurance policies can be quite wide, particularly in relation to medical claims. A propensity to develop infections like UTIs can mean a person meets the definition of a PEMC, and the insurer can decline the claim.