Travellers who were forced to end their trip early when a member of their group fell ill will be required to provide more information about the man's hospitalisation, after a dispute ruling sided with their insurer. 

The complainants were on holiday in India when the man, referred to as JS, contracted a urinary tract infection and was forced to spend a week in a hospital in Lucknow. 

The group cut the trip short after JS was discharged and sought cover for cancelled tour expenses and overseas medical costs.   

Insurer AWP Australia acknowledged JS had been hospitalised but argued it required more information about his stay, noting he received treatment relating to a wound on his foot and an undefined “plastic surgery”.   

The insurer was concerned the treatments may have related to JS’ pre-existing type 2 diabetes and hypothyroidism, which would be excluded under the policy. The procedures also revealed a pre-existing cyst on one of the man’s kidneys, which the insurer said may have been relevant. 

It asked JS to provide information relating to his medical history and follow-up appointments when he returned to Australia, and details on the “plastic surgery”.   

JS argued he provided adequate information to process the claim and the insurer’s request was unreasonable and a “contravention of consumer protection laws and medical confidentiality requirements”.   

He said the “plastic surgery” was not akin to procedures that would be referred to as plastic surgery in Australia and it was the insurer’s responsibility to discover what the hospital meant by the term.    

The Australian Financial Complaints Authority says AWP Australia is entitled to know if any pre-existing conditions played a role in the man’s illness.   

It notes that JS’ claim form states his infection stabilised after three days and that he stayed in hospital with “other complications”. It also says a hospital summary recorded the man’s “diabetic foot” as a co-morbidity. 

The claimant said he had not seen a doctor for either of his pre-existing issues for more than two years, and that when he last received treatment for his diabetes, he had travelled not long after.    

The ruling acknowledges JS’ contention but says his explanation does not respond to the insurer’s valid queries about his hospitalisation.   

“While JS says, and I accept, this condition has been well maintained via treatment with medication, it is certainly possible, on the face of it, that the diabetes could have played a causal role in the need for JS to be hospitalised,” the authority said.   

“Indeed, the terms ‘plastic surgery’ and ‘Betadine ointment for local application over wound over foot’ that are set out in the medical records of Medanta Hospital could potentially be treatment for a common complication caused by diabetes type 2.

“Given these considerations, I am satisfied the insurer’s request for further information is reasonable. It follows it may withhold a claims decision until the further information is provided by JS.”   

The decision notes the complainants lodged a similar claim under a separate policy with another insurer. It says even if AWP Australia accepts liability, it will be required to pay only once that claim reaches its outcome.   

Click here for the ruling.