Trauma cover conditions not met
Rachel's insurer said she didn't meet the specific requirements for trauma cover, so declined her claim.
Rachel's insurer said she didn't meet the specific requirements for trauma cover, so declined her claim.
Rachel* held various insurance covers, which included trauma cover.
She became unwell and developed blood clots and, in June 2023, she underwent surgery for chronic thromboembolic pulmonary disease and small patent foramen ovale.
Rachel made a claim under the trauma cover of her policy. However, the insurer declined her claim, because her condition and the surgery did not meet the specific requirements of the trauma cover.
Rachel made a complaint to the IFSO Scheme. She said, when she first got the policy, she clearly stated that she wanted to be covered for everything.
The IFSO Scheme looked at Rachel’s policy, and found that the lung disease cover did not apply, because she had not suffered “end stage respiratory failure as diagnosed by an appropriate specialist”.
The heart surgery cover did not apply, because open heart surgery was only covered if it was on the valves or aorta.
Finally, the pulmonary hypertension cover did not apply, because Rachel had not suffered impairment “to the degree of at least Class 3 of the New York Heart Association classification of cardiac impairment as confirmed by a cardiologist”. Prior to the surgery, Rachel had only been classified as Class 2.
While Rachel said that she asked for cover for everything, insurance does not cover everything. Instead, the cover is set out in the terms and conditions of each policy. Trauma cover, in particular, only covers specific defined circumstances, not simply traumatic events.
Generally, it is up to consumers to read and understand the terms and conditions of their policies. If there are unusual conditions in a policy, insurers must bring these to the attention of the insured. In this case, however, because specific conditions are common in trauma cover, Rachel’s insurer was not required to bring them to her attention.
Rachel’s insurer was able to decline her claim, because it didn’t meet the conditions in her policy.
Complaint not upheld
*Name has been changed
Generally, it is up to consumers to read and understand the terms and conditions of their policies. Trauma cover commonly only covers certain circumstances, such as specific conditions or surgery.