Insurer refused claim because of pre-existing condition

Insurance Medical Conditions

Bodhi contacted us after his insurer declined a claim on his private health insurance policy for treatment of a lung condition.

What happened

Bodhi had been diagnosed with a lung condition shortly before he took out a private health insurance. He made a claim on his policy for treatment for his lung condition soon after, but his insurer declined the claim. His insurer said his policy didn’t cover him for pre-existing medical conditions.

Bodhi had no idea he wasn’t covered and felt he was treated unfairly. So he complained to his insurer. Unhappy with its final response, he approached our service for help. 

What we said

We asked Bodhi what happened and he said no one had explained that he wasn’t covered by the policy until now. We checked the policy terms. These explained that pre-existing medical conditions weren’t covered. We also asked the insurer for the medical evidence it had relied on. The GP’s notes showed that Bodhi had been diagnosed with a lung condition shortly before he took out the policy.

We checked how Bodhi had taken out the policy. The insurer explained he’d taken out the policy online and showed us a screenshot. The screenshot explained to Bodhi that any pre-existing medical conditions wouldn’t be covered by this policy.

We explained to Bodhi that we thought the insurer had given him enough information about the policy to decide if it was right for him. We said it was reasonable for the insurer to reject the claim because the terms excluded pre-existing medical conditions.