Gerry and Mary book an adventure
In July 2014, Gerry and Mary started paying instalments for a cruise to Antarctica in April 2015.
The lump
Around 26 November 2014, Gerry had noticed a small lump on his anus. Mary said Gerry should go to the doctor to have it looked at. On 9 December Gerry went to his doctor. His doctor suspected the lump was a haemorrhoid and not a concern but referred him to a specialist for a conclusive diagnosis.
On 18 December Gerry and Mary purchased travel insurance from Icy Adventures. When asked about any medical issues Gerry did not mention the lump.
On 24 December, the specialist confirmed Gerry’s lump was a haemorrhoid. During questioning by the specialist, Gerry told the specialist he had suffered a bout of diarrhoea and a minor change in bowel habits. The specialist then performed a colonoscopy and found a tumour. Gerry was diagnosed with bowel cancer.
On 10 February 2015 Gerry had an operation to remove the tumour. Unfortunately, Gerry suffered post-operative complications and was going to be too sick to travel. Gerry cancelled his cruise to Antarctica but he expected a full refund from his travel insurance.
Icy Adventures declined Gerry’s claim saying it arose from a pre-existing medical condition (the diarrhoea and change in bowel habits), which was not covered. Gerry thought this was unfair because the lump was the only symptom he had when he purchased travel insurance and it had been confirmed to be an unrelated haemorrhoid. Gerry complained to FSCL.
The clause
Icy Adventures told FSCL they had declined Gerry’s claim on the basis of an exclusion clause in the policy. The exclusion clause said that Icy Adventures will not pay under any circumstances if:
“Your claim arises from, is related to or associated with any signs or symptoms that you were aware of before cover commenced, but;
a) You had not yet sought medical opinion regarding the cause; or
b) You were currently under investigation to define a diagnosis; or
c) You were awaiting specialist opinion.”
This clause covered situations where an insured is aware of signs or symptoms, but there is not yet a confirmed diagnosis. Icy Adventures said even if the lump was unrelated, Gerry’s diarrhoea and change in bowel habits were ‘signs or symptoms’ associated with bowel cancer which Gerry had not yet sought a medical opinion for.
Review
We noted that Gerry initially went to his doctor to diagnose his lump. There was no mention to the doctor of diarrhoea or a change in bowel habit in the doctor’s notes or the referral letter sent to the specialist. We considered that when Gerry bought the travel insurance he was not “under investigation” or “awaiting a specialist opinion” for these symptoms, so these sections of the exclusion could not apply.
We also found that Gerry had no intention to seek a medical opinion about his diarrhoea or change in bowel habit because he did not consider them to be serious. Gerry thought the symptoms were due to a change in his usually strict diet.
We concluded it was reasonable for Gerry to not seek a medical opinion for these symptoms or to disclose them to Icy Adventures because they were of short duration ad could have had a multitude of causes, not limited to bowel cancer. We considered that the policy exclusion could not apply here because it was likely Gerry would not have gone to see a doctor at all until there were more serious symptoms of bowel cancer.
We found that Gerry was entitled to cover under his travel insurance. Icy Adventures agreed to pay Gerry the full refund of $8000 for the travel he had purchased.
The lesson for consumers
It is important to disclose any potentially concerning health issues to your insurer when buying travel insurance. Exclusion clauses for pre-existing medical conditions are often drafted broadly to cover many medical issues which may show few early signs or symptoms. It pays to read the policy carefully.
