On the last day of Paul’s holiday in Australia he damaged his tooth, causing him considerable pain. As Paul was unable to get a dental appointment before leaving, he travelled home to New Zealand and immediately saw a dentist. The dentist repaired the tooth but advised the repair may not last, and Paul might need a crown replacement within the next couple of years.
Paul wrote to his insurer about the tooth damage, but advised he did not wish to submit a claim as the repair cost only $60. Paul warned his insurer that if he needed more extensive repair work, he would submit a claim then. Paul did not hear back from the insurer.
Four years later the repair failed. Paul’s dentist advised it would cost $1,500 to replace the crown and Paul submitted a claim.
Paul’s insurer declined the claim, explaining the policy only covered Paul’s emergency dental costs incurred outside New Zealand while he was on the journey. As the costs for both the original repair and the proposed repair were incurred in New Zealand, the policy did not cover the costs. The insurer also advised it had no record of receiving Paul’s advice about a potential future claim.
Paul’s view
Paul considered the insurer’s decision was unreasonable. Paul did not have enough time to wait for a dental appointment in Australia while he was on the journey. Instead, he returned to New Zealand and, in good faith, chose the cheapest repair option to save his insurer money. Paul said he told the insurer about the potential future claim, but the insurer did not reply.
In Paul’s opinion, the insurer would have been liable for a crown replacement to his tooth in Australia in 2012. Paul considered it unfair for the insurer to now decline a claim simply because he returned to New Zealand to save the insurer unnecessary expense.
Review
We explained to Paul the policy covered the cost of emergency dental treatment:
- for the relief of sudden and acute pain
- given by a qualified medical practitioner
- incurred outside New Zealand
- as a result of accidental injury or illness
- during the journey.
There was no dispute that Paul had experienced sudden and acute pain caused by an accidental injury while Paul was on his journey. However, the policy also required the dental treatment cost to be incurred outside New Zealand. Paul’s dental treatment took place within New Zealand, both in 2012 and 2016.
We went on to explain that even if Paul had been treated in 2012 in Australia, and that treatment was now failing, his insurer would not be liable for the costs of treatment now proposed.
The insurer was only ever liable for the cost of emergency dental treatment to relieve Paul’s pain necessarily incurred outside New Zealand. It was therefore unlikely the insurer would have agreed to cover the cost of a replacement crown in Australia in 2012. If Paul had been unable to travel home for treatment, it was more likely the insurer would have covered the conservative repair costs similar to that performed by the dentist in New Zealand in 2012.
Outcome
Although Paul agreed to withdraw his complaint, he remained of the view the insurer was using the policy wording to avoid paying a legitimate claim.
Our insight
All insurance comes with limitations. Travel insurance is designed to cover the cost of overseas medical treatment if the insured cannot be brought safely home. Once the journey is ended, it is usual for travel insurance policies to end, and for medical expenses to be either borne by the New Zealand medical system or the individual themselves.
