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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.
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IMB/1886/L Treatment Necessitated by accidental injury
The assured alleged that she had a fall in the bathroom which caused her nose to bleed. According to the medical report the assured sustained septal deviation and a surgery ( rhinoplasty of the nose ) was performed. The assured's claim for reimbursement of medical expenses incurred was declined by the insurers on the ground that the treatment received by the assured was for a specific illness ( All ear, nose ( including sinuses ) and throat conditions requiring surgery ) which occurred during the first policy year and thus excluded by the policy.
Based on the medical report the assured's treatment was not for an illness. The treatment was necessitated by an accidental injury and thus the specific illness clause is not applicable in the circumstance of the case. Accordingly the Mediator found the insurers liable to settle the insured's claim.
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