SERVICE: Health
OUTCOME: Not upheld
Issues: Policy Exclusion
Mr and Mrs P held health insurance with the insurer.
The policy included cover for pre-existing conditions, including breast cancer.
On 31 October 2023, Mrs P told the insurer that she had undergone a left mastectomy and required bilateral reconstruction with fat grafting, as her right breast implant had been removed in 2021 due to an implant rupture. Mrs P made a claim for the reconstruction surgery.
The insurer partially accepted the claim in relation to the left breast reconstruction, but declined to provide cover for the right breast reconstruction.
The policy excluded cover for subsequent breast reconstruction surgery or symmetry surgery, unless completed within 2 years of the first eligible breast reconstruction surgery (following an eligible mastectomy).
Mr and Mrs P made a complaint that the right breast construction should have been covered under the policy, because it was required due to the implant rupture, not because of a previous reconstruction surgery.
The case manager’s assessment
When an insured makes a claim under an insurance policy, the law says that it is up to them to prove that they have suffered a loss, which is covered by the policy. [1]
The insurer can then choose whether to apply a policy condition or exclusion to limit or decline a claim. If the insurer does choose to do so, it must prove the condition or exclusion applies.
Mrs P’s breast surgeon confirmed that that she had a breast implant inserted in 2004, following a right breast mastectomy in 2003. In 2021, the implant was removed, because it ruptured.
The sequence of events was sufficient to say that Mrs P’s right breast reconstruction in 2023 was required in relation to, or as a consequence of, her first breast reconstruction in 2004, which had happened more than 2 years earlier. Therefore, the insurer was able to apply the exclusion to decline the claim.
Complaint No: 00231206
[1] This is known as a prima facie claim.