A complainant who lodged a claim for death benefits after his wife contracted covid while on a cruise ship will receive limited cover following a dispute ruling panel’s decision. 

The man and his wife, referred to as K, had been on a scheduled cruise from March 8 to March 21 2020, before a Covid-19 outbreak prompted an earlier-than-planned return. 

K, who had contracted covid, was admitted to a hospital on March 20 and died a few days later. The claimant sought $50,000 from the multi-trip travel insurance policy’s death benefits to cover associated costs. 

Mitsui Sumitomo Insurance declined the claim, saying that K’s death did not fit the policy’s definition of injury described in the Product Disclosure Statement (PDS).

The complainant said the insurer could not rely on the policy’s terms and exclusions because it failed to provide him with the PDS. He said he had only received a certificate of insurance (COI) when he purchased the policy in June 2019.

The insurer disputed the policyholder’s position, saying that the PDS and COI are automatically sent together. It also noted that the complainant had not mentioned this information during the claim assessment period or internal dispute process. 

It says that screenshots, provided to the Australian Financial Complaints Authority (AFCA) panel, showed that a quote was converted into a policy on June 19 2019 and that the complainant received a copy of the COI. 

However, the panel noted that the COI provided by the insurer was several pages shorter than the one supplied by the claimant.

AFCA said that the information provided by Mitsui Sumitomo Insurance did not show any copies of emails containing the documents that were sent to the complainant and that it failed to explain if the PDS had been delivered. 

It said that given the insurer’s failure to show it gave the policyholder the relevant documentation, it could not rely on the policy terms for its claim denial decision.

AFCA acknowledged section 35 of the Insurance Contracts Act 1984 (cth) (the Act), which states that if an insurer “cannot demonstrate it has clearly informed the complainant of the terms it seeks to rely on, it is required to pay the minimum amount declared by the Regulations”.

It said that the Act stipulates for the insurer to cover medical, ambulance and treatment costs for an insured person who incurs sickness during a specified journey.

But the panel said that Mitsui Sumitomo Insurance was not required to cover funeral and transportation costs because K had not died during the trip but rather days later in the hospital. 

“It is fair that the complainant be entitled to claim under standard cover provided by the Regulations,” AFCA said.

“It is also fair that the insurer be permitted to limit its liability to only such cover that is available to the complainant under the Regulations.”

Click here for the ruling.