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					GROUP: Health Insurance
SERVICE: Health
Complaint No : 109409
YEAR: 2001

Casebook Index: Cosmetic purposes, Exclusion - Health, Scope of cover.


Complaint

C’s work situation had changed and he worked many hours water blasting walls and
other surfaces. While doing this, dirt and water settled on his glasses or would
interfere with his use of contact lenses. C found it almost impossible to continue
working wearing glasses and, in order to keep his job, C was of the opinion that he
needed eye surgery to correct his short-sightedness. C filed a claim for reimbursement
for the eye surgery with P. P declined the claim, on the basis that “surgery for the
correction of refractive visual errors” was excluded from the policy cover.

Assessment

P’s policy clearly stated that the kind of surgery C required was excluded. An insurer
is entitled to determine the scope of its cover and the wording of the contract. Most
insurers in the industry do exclude eye surgery of this kind, as it can be regarded as
cosmetic surgery. The Case Manager did not believe that P’s exclusion was
unreasonably harsh or unfair and it did not deviate from insurance industry standards.
P had correctly applied the policy exclusion and had been entitled to decline the claim
in accordance with the policy wording.

Result Complaint not upheld

				
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