A complainant who claimed for Temporary Total Disablement (TTD) after he was diagnosed with renal failure and chronic kidney disease has successfully challenged his insurer’s denial. 

The insured held a group accident and sickness policy and filed the claim after he was diagnosed with the conditions in May 2022. The claimant provided supporting medical certificates from his treating GP and a second doctor’s opinion.

Allied World Assurance Company says the claimant’s disablement arose from pre-existing conditions from more than 12 months before the policy was purchased in April 2020, and was excluded from cover.

It argues the insured’s medical history showed that previously diagnosed hypertension and diabetes contributed to the renal failure. 

The insurer relied on findings from a medicolegal nephrologist who says the complainant’s hypertension had been “largely uncontrolled” and that his chronic kidney disease had been present since at least 2011. 

The nephrologist says the man’s estimated Glomerular Filtration Rate (eGFR) levels from 2013 had been classed as stage 3 chronic kidney disease, which by May 2022 had fallen to stage 4 levels. 

The report also noted that the complainant had previously received treatment for renal impairment in 2012.

The complainant’s doctor, referred to as Dr DSE, acknowledged that the claimant had a “long history” of chronic kidney disease since 2009 but said the renal failure first showed symptoms in May 2022. 

Dr DSE attributed the claimed conditions to hypertension, which the man was diagnosed with in 2005, and type 2 diabetes, which was diagnosed in 1989. 

The Australian Financial Complaints Authority (AFCA) accepted that the findings from the doctors established that the man’s chronic kidney disease and renal failure stemmed from his previous existing conditions and medication he had been taking.

However, it says the claimed conditions had only become symptomatic in 2022 and that the man had not been previously aware of these ailments.

“The complainant had chronic kidney disease since 2009 or 2011,” AFCA said.

“However, there is no reliable evidence he was aware of it or that he was receiving treatment or advice in the relevant period (the 12 months prior to 30 April 2020). There is no evidence he had renal failure in the relevant period.

“These conditions are not pre-existing conditions unless their connection to other conditions makes them so.”

The ruling also agreed that despite the illnesses being caused by the complainant’s pre-existing conditions, it was not fair for Allied World Assurance Company to exclude the claim.

“These conditions are caused by his diabetes and hypertension, but that is not enough,” AFCA said.

“Renal failure and chronic kidney disease will only be pre-existing conditions if they are themselves a 'side effect' or 'symptom' of diabetes and hypertension.” 

AFCA required the insurer to accept the claim and award the complainant all unpaid benefits as well as interest on any benefits after the claim had been denied in January last year.

Click here for the ruling.