Holly purchased travel insurance in March 2016 to cover her family’s trip to Europe from 30 November 2016 to 10 January 2017.
While on her trip, Holly saw a doctor in the Netherlands for treatment in relation to a urinary tract infection (UTI), for which she was prescribed antibiotics. The treatment cost was $262.
The insurer saw that Holly had received previous medical treatment for UTIs over the course of November and December 2015. Holly’s doctor’s records noted that Holly had suffered from six UTIs in 2015.
The insurer relied on an exclusion clause, which said there was no cover for a pre-existing medical condition (PEMC), to decline Holly’s claim.
The policy defined “pre-existing medical condition” as
A medical condition Holly was aware of in the two years prior to the policy being issued… for which Holly had been prescribed a new medication or had a change to her medication routine
In the two years prior to purchasing her travel insurance policy it was clear that Holly had suffered from recurrent UTIs.
As a result of the declinature, Holly complained to FSCL.
Insurer’s view
When Holly bought the policy she was aware that she had suffered six UTIs during 2015 and required treatment with three different types of antibiotics. It was clear that the UTI’s were a medical condition for which Holly had been prescribed medication in the last two years, and were a PEMC. The insurer noted that if Holly had wanted additional cover for her UTIs she should have declared the condition and completed a medical assessment.
Although the insurer was confident it was not liable for the costs, it offered to pay 50% of the costs (after the $150 excess was deducted) on an ex gratia basis.
Holly’s view
Holly believed that each infection was an isolated incident. Therefore, the UTI Holly suffered while she was overseas could not be considered to have arisen from a pre-existing medical condition. The medical tests always showed that the cause was a common bacterium and Holly’s GP stated that there was no cause for concern.
Holly argued that, because her doctor had said there was no cause for concern and had given her different medication, she couldn’t have known that she should have declared the condition. Holly also maintained her doctor had told her that UTIs weren’t pre-existing medical conditions.
Holly rejected the ex gratia payment from the insurer and asked us to continue our investigation.
Review
Due to the frequency of past medical visits for UTIs in the year preceding the policy, we thought it was reasonable to expect Holly to inform her insurer of the condition. Without this information, the insurer could not make an informed decision on whether to provide cover for the condition (possibly at a higher cost) or conduct further investigations or assessments of the condition.
Though the definition of pre-existing medical conditions was very wide, insurance policies are contracts and must be interpreted as such, giving effect to the meaning of the words as defined in the policy.
Although the UTIs may not have been pre-existing conditions in Holly’s, or her GP’s eyes, they came within the policy definition as conditions for which Holly had sought treatment, and been prescribed medication for in the previous two years. The condition was captured by the exclusion clause.
We found that the insurer was entitled to decline Holly’s claim and recommended that she discontinue her complaint.
Key insight for consumers
It pays to read your policy and the associated definitions.
