Aja travelled overseas to Germany, Canada and The United States from December 2016 to June 2017 to conduct research for work. Travel insurance cover was provided through Aja’s employer’s group policy.
In March 2017, Aja visited a hospital in the United States for a consultation for her attention deficit hyperactivity disorder (ADHD) and to obtain her usual medication. In order to ensure that the dosage was correct and that she was not developing side effects, Aja required monthly assessments.
Aja paid $314.99 USD for the consultation and a prescription for ADHD medication.
The insurance policy
Aja claimed the medical expenses under her employer’s insurance policy, as medical expenses relying on a clause which said;
We will reimburse the insured person
The reasonable cost of medical expenses and additional expenses as a direct result of the sickness of or injury to the insured person, occurring during the period of insurance and whilst on a journey,
The insurer declined Aja’s claim because of two exclusion clauses which read
We will not pay for any expenses
Incurred for any medication for a condition which commenced prior to the commencement of a journey and the insured person has been advised to continue the medication during the journey
We will not pay for any expenses
incurred for routine or elective medical, optical or dental treatment or consultation.
Aja didn’t think that either of these clauses applied to her circumstances and complained to FSCL.
Aja’s view
Aja had a claim accepted in February for her ADHD medicine. She didn’t know why it should be declined now.
‘Advised to continue medication’
Aja stated, that because of the potential side effects and consequences from her medication, it was important to ensure that dosages and other contingencies were regularly assessed. Aja did not believe that the first exclusion applied to her, because a doctor could not advise her to take the medication for the entirety of the trip. In Aja’s eyes, the medical recommendation could only be made by the prescribing doctor on the medical conditions and symptoms given in any one month. Aja disputed she had been advised to take the medication before she left New Zealand because each assessment had to be done on a monthly basis with reference to her psychological state, body weight, blood sugar and other contingencies.
‘Routine medical consultation’
Aja did not believe that the second exclusion applied because her appointments to assess ADHD were not ‘routine medical treatments.’ Aja believed, because the outcome could be different in each instance (if there were changes in contingencies), they were not ‘routine.’ Aja believed that ‘routine medical consultations’ were preventative appointments considered as part of a healthy lifestyle to stop diseases before they become symptomatic
Insurer’s view
Although ADHD was listed on her pre-existing medical conditions for cover, Aja was only covered for a sickness during the period of insurance which included any new and unforeseen events linked to her ADHD (i.e. unexpected reaction to medicine requiring hospitalisation). Aja’s claim did not relate to a new and unforeseen event.
The insurer disputed Aja’s interpretation of ‘routine,’ asserting that, as Aja was required to attend a medical practitioner on a monthly basis, the appointments were routine. There was no need to distinguish between alleviative and preventative purposes.
The insurer also believed that Aja’s ADHD medicine was medication which she commenced taking prior to the journey. Aja would have had no reason to find a doctor overseas to prescribe ADHD medication if she had not already started the medication in New Zealand. It did not matter that Aja only had to take the medication while she was working.
Aja’s February claim was accepted in error. However, that mistake did not obligate the insurer to accept subsequent claims. Insurance policies, by their nature will only cover unforeseen events. No insurance policy will cover every eventuality.
Review
The wording of the first exclusion clause only referred to medication for a condition rather than ‘refill,’ ‘repeat,’ or ‘new.’ The insurer was correct in determining that there was no need to differentiate between the reasons for getting a new prescription. The material fact was that Aja needed a new prescription.
In regards to the second exclusion clause, we applied a plain English interpretation of routine medical treatment, though it was not the same as Aja’s view. There was no need to differentiate between preventative and alleviative illnesses when discussing what constituted a routine medical treatment. Visiting the doctor to obtain a prescription for ADHD medication when Aja was working was part of her routine.
It would not have been reasonable to hold an insurer liable for foreseeable medical expenses incurred by Aja as a result of ongoing routine consultations and prescriptions. This was not the insurance policy’s intention.
As a result, we recommended Aja discontinue her complaint.
Key insight for consumers
Travel insurance is a contract of insurance. As with all contracts of insurance, limitations of cover and exclusions apply. It is important to realise that if words are not defined in the policy, the interpretation of insurance policies is subject to plain English and common understandings of the words used.
