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AFCA ruling puts down marker on pre-existing conditions

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The Australian Financial Complaints Authority (AFCA) has set out what it defines as a pre-existing medical condition in a travel insurance dispute ruling.

AFCA says a medical ailment qualifies as a pre-existing condition if a claimant has symptoms that they know are likely to be caused by a serious condition.

"If a person had symptoms of a serious condition, but reasonably believed them to be symptoms of an innocuous condition, AFCA will treat that person as having been unaware of the serious condition," it said.

"If a person had symptoms of a serious condition, and a reasonable person would have known they were likely to be symptoms of a serious condition, AFCA will treat that person as having been aware of the serious condition, even if it was not yet diagnosed."

In the dispute determination, AFCA dismissed the complaint from the claimant, who said she was not aware she had a “serious medical condition” when the travel insurance policy was purchased from Southern Cross Benefits in July last year.

She had seen her GP on a few separate occasions and was given medication for her persistent cough and nausea. The GP finally referred the complainant to a hospital emergency department for her nausea and abnormally fast heartbeat on July 27. But before going to the hospital, she purchased the travel policy through the insurer’s website.

The claimant was then diagnosed with congestive cardiac failure and medically assessed as unfit to travel. After she was discharged from hospital on August 1, she cancelled her holiday and lodged her claim with Southern Cross Benefits.

AFCA says the claimant’s cardiac-related illness qualified as a pre-existing medical condition even though it had not been medically diagnosed when she bought the travel insurance policy.

It says the timeline of actions and supporting documents provided suggest “a reasonable person in the complainant’s position would know they were likely to have a serious medical condition”.

“When the complainant took out the policy, she had been experiencing nausea for nine days. She had visited her GP three times in five days. She had been referred to a hospital emergency department,” AFCA said in the ruling.

“And the tachycardia was the reason for the hospital referral. The complainant did not know what illness she had when she took out the policy. However, she knew she had an illness, and a reasonable person in her position would have known the illness was likely to be serious.

“Therefore, the complainant’s awareness was sufficient for the illness to fulfil the policy’s definition of pre-existing medical condition.”

AFCA also was not persuaded by the claimant’s argument that the insurer’s online purchase form prevented her from reporting her symptoms.

She could have called the insurer directly, AFCA said, and if she did, it was unlikely Southern Cross Benefits would have agreed to cover the medical symptoms she was exhibiting.

“The insurer is not obliged to offer cover for any condition,” AFCA said.

AFCA upheld the insurer’s decision to decline the claim.

Click here for the determination.