GROUP: Fire and General Insurance
Complaint No : 109327
Casebook Index: Pre-existing condition, Service issues.
C was hospitalised while travelling in Australia. The cause of the hospitalisation was
considered to be either a stroke, or a migrainous attack. On returning to New
Zealand, C made a claim for the costs associated with the hospitalisation. After
obtaining C’s medical records, P declined the claim on the basis that the attack related
to a pre-existing condition. C’s medical records confirmed that C suffered from
migraines 3-4 times a year.
C argued that there was no conclusive diagnosis for the attack. Also, he was
concerned that he had not received the level of service required from P’s 24 hour
emergency organisation and, because of that failure, had been transported to a private
hospital and incurred extra costs.
C had established a prima facie claim under the policy. As P was relying on an
exclusion to decline cover, the burden was on P to prove the application of the
exclusion on the balance of probabilities.
The medical opinion from Australia suggested that C’s attack may have been a stroke,
but it also may have been atypical migraine symptoms. C’s doctor in New Zealand
considered the opinion but, following a specialist’s advice, determined that no further
tests were needed, suggesting it was most likely the attack was related to a migraine.
P’s consultant physician formed the opinion that, because of the relatively short length
of the attack and the fact that C had a clear CT scan following the attack, it did not
appear that C had suffered a stroke, when the proper definition of a stroke was
considered. The most realistic possibility was that C had suffered atypical migraine
symptoms. On this basis, it was considered that P had established the application of
the exclusion to the relevant standard.
However, the Case Manager was concerned that, when C contacted P’s 24 hour
emergency organisation, it was unable to provide him with a doctor and advised him
to contact the hotel doctor. The hotel doctor sent C to a private hospital, without any
consultation with C. Although C was then transferred to a public hospital, he incurred
extra costs associated with the transfers and also relating to the procedures carried out
in the private hospital.
P acknowledged the service provided by its agent was less than satisfactory and that it
may have contributed to the level of costs incurred by C. Accordingly, P made an ex-
gratia offer to C of 25% of the claimed amount in resolution of the complaint and in
acknowledgement of the extra difficulty suffered by C. C accepted the offer.
Result Complaint settled