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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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FMB/LI 0237 Whether Hospitalization Was Due to Complication of an excluded illness
The assured suffered from acute myocardial infarction and an emergency coronary artery bypass surgery was performed on 18.4.2005. It was stated in the medical report that the assured had been suffering from mild diabetes for about two years.
The insurers declined the claim for hospital and surgical benefit on the ground that it falls under policy exclusion on " hospitalization arising directly or indirectly, wholly or partly from diabetes mellitus and related complications ". The insurers' decision was based on the medical findings that diabetes is a risk factor for coronary artery disease. The insurers maintained that the assured's hospitalization was due to complication of his diabetes which is excluded by the policy.
The assured's attending doctor was of the view that the assured's myocardial infarction was not due to the complication of his diabetes, taking into consideration the short duration and mild condition of the diabetes. The consultant Cardiothoracic Surgeon reported that the risk factors for the assured's heart disease have been predominantly smoking for 35 years and hypercholesterolemia.
Thus, although the assured suffered from diabetes, his heart disease may not be due to the complication of his diabetes since there were other predominant risk factors, i.e smoking for 35 years and hypercholesterolemia. The benefit of the doubt should be given to the assured. Accordingly the Mediator held that the exclusion clause was not applicable and the insurers were liable to settle the assured's claim.
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