Leila’s insurer declined her claim for breast reduction surgery on the basis that it was a cosmetic treatment.
Leila’s insurer declined her claim for breast reduction surgery on the basis that it was a cosmetic treatment. The policy didn’t have a specific exclusion for the removal of healthy tissue.
How we helped
We checked Leila’s medical records which showed that she’d started experiencing acute back pain. We checked this with her consultant. He confirmed all other options had been ruled out and that surgery was the only way to relieve her symptoms, which were severe. He said there was a direct link between the back pain and the need for the reduction.
The consultant was a recognised specialist in this field. So, when we compared it to the insurer’s medical report, we were more persuaded by what her treating consultant had to say.
We explained to the insurer that we didn’t think it was fair for them to rely on the exclusion for cosmetic surgery. We said the insurer should pay the claim as the medical evidence confirmed the surgery was intended to relieve the symptoms of her back pain, and wasn’t cosmetic.