Case Review: Insurance
Summary of some of the decisions made by the Mediators on some of the complaints received by FMB.
This summary is for information only and should not be used for other purpose.
FMB/GI 0302 - Treatment for Pre-Existing Illness
The insured was admitted to the hospital on 20.12.2004 due to chronic cholecystitis. According to the medical report the symptoms of the illness had existed since 2001, i.e prior to the policy commencement date on 25.10.2002. The insurers declined the claim on the ground that the policy does not cover treatment for pre-existing illness.
The relevant policy exclusion states as follows:-
"In connection with an existing sickness or injury, benefit will not be paid
(a) for any admission commencing before 24 months has lapsed from the effective date"
The policy exclusion does not state that benefits will not be paid for treatment of a pre-existing illness. It states that for an existing illness benefit will not be paid for any admission commencing before 24 months has lapsed from the effective date. In the matter under reference the insured had an existing illness as defined in the policy, but his admission was after 24 months of the policy effective date. Thus the policy exclusion on existing sickness is not applicable.
Upon being queried the insurers revised their decision and approved the claim.