FSCL Case Study

In July, a woman discovered a lump in her breast She went for a scan in August and, in September, was told that it was benign, but that it should probably be removed. She scheduled the operation for November.

In October, she and her partner booked flights to travel to Australia in February for a friend’s wedding

She became very busy at work, so went to her specialist and rescheduled the operation for January.

Following the surgery in January, she was diagnosed with breast cancer and required immediate treatment. The follow-up treatment was scheduled for the same time as the planned trip and she and her partner cancelled the flights.

The woman and her partner were relying on complimentary credit card travel insurance for the trip. When they cancelled the trip, they submitted a claim, but the insurer declined it on the grounds that the loss was caused by a pre-existing medical condition.

Dispute

The woman said this was very unfair. Although she knew about the lump, she had no idea how serious it was. She submitted a statement from her surgeon confirming that the cancer diagnosis came as a complete shock that neither he nor the woman were expecting.

The insurer responded, referring to the policy wording which referred to any “sickness, injury or condition which has occurred or which you have been aware of, or for which treatment, medication or medical attention has been sought…”. Although the woman did not know she had cancer, she knew that she had a sickness which required treatment, which she had not disclosed. The insurer maintained its decision to decline the claim.

Review

FSCL agreed the insurer was entitled to decline the claim. It explained that the phrase “pre-existing medical condition” took on a special meaning within the context of the insurance policy. A pre-existing medical condition is defined to include any sickness, which was defined as any illness or disease, including symptoms.

FSCL said that, although the woman did not know she had cancer, she knew she had symptoms that could indicate cancer and, at the very least, required a surgical procedure. The pathologist’s report following the biopsy diagnosed a fibroadenoma and an atypical lobular hyperplasia (B3). The surgeon’s notes from the appointment in October, when the woman delayed the surgery, indicated that although he did not know she had cancer, he knew enough to be concerned.



September 2020

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