SERVICE: Travel
OUTCOME: Settled
Issues: Pre-existing condition
On 2 March 2023, Ms J purchased insurance for her holiday in New Zealand from 22 to 28 March 2023.
Ms J had to cancel the holiday, because her daughter was diagnosed with cancer. Ms J made a claim for the non-refundable costs of her holiday.
The insurer declined the claim and said Ms J’s daughter had been aware of her symptoms and had a medical examination prior to the date Ms J purchased the policy. The insurer referred to the policy’s pre-existing condition exclusion.
Ms J complained that, when she arranged the policy, she did not know about her daughter’s illness. She said she would not have planned a holiday if she had known about it. Ms J said her daughter’s condition was not a pre-existing condition, because she had not spoken to Ms J or her doctor about it when Ms J arranged the policy in good faith.
The case manager’s assessment
The insurer was able to decline to pay the full claim, because the policy did not cover loss “directly or indirectly caused by or arising from … Pre-existing Medical Condition(s) of Your Close Relatives or any Complications attributable to those condition(s), except specified under section 1.1 d)”. The policy defined “Pre-existing Medical Condition” as (a) “Any physical defect … of which … the person due to whom You are claiming, are aware of” or (b) “Any medical condition for which … the person due to whom You are claiming have … received a medical … consultation … in the 12 months prior to the date Your policy was issued.”
Ms J’s daughter was a “Close Relative” as defined by the policy. Because she went to the doctor about her symptoms before Ms J arranged the policy (although no-one knew what the symptoms were at that stage), this meant she had a “Pre-existing Medical Condition”. Because the claim was related to that condition, the insurer was able to decline the claim, unless it came within section 1.1 d). Section 1.1d) provided limited cover ($1,500 per insured person, up to $3,000) if Ms J had to cancel her journey because of circumstances that were unexpected and unintended by her and if a close relative was hospitalised after the policy was issued as a result of a “Pre-existing Medical Condition”.
Ms J said her daughter was in hospital when she was given the cancer diagnosis and this was also when the doctor told Ms J to cancel the trip.
The case manager discussed the complaint with the insurer and it agreed to pay Ms J the maximum amount under section 1.1d). Ms J accepted this amount in settlement of her complaint.
Complaint No: 00231204