A woman who was hospitalised on holiday will not be covered for her expenses after the complaints authority sided with her insurer, which found her illness stemmed from morbid obesity that she did not declare.

The complainant had trouble walking shortly after arriving in the US in January 2019 and was later diagnosed with a urinary tract infection and swelling in both legs.

She was due to return to Australia on February 27 but could not because the plane did not have adequate disability access. The next day, she reported further complications, including no longer being able to walk, and was taken to hospital for treatment on her swollen legs. 

The woman was cleared to leave the hospital on March 10 but stayed another five days while awaiting Zurich Insurance’s decision.

In rejecting the claim, the insurer referred to a report from a consultant geriatrician and medical oncologist who found the woman had suffered leg swelling for at least 20 years. The doctor concluded the woman suffered from several medical conditions including excess weight – which had been above 200kg – recurrent leg ulcers and cellulitis, knee osteoarthritis and chronic leg swelling.

The US hospital declared the woman’s illness stemmed from her obesity and vein issues.  

Zurich said its travel policy would not cover claims arising from pre-existing conditions and if it had been aware of her obesity and other chronic issues, it would not insured the woman. 

The complainant said her hospitalisation was not related to her pre-existing conditions and the insurer had “forced the [US] doctors to diagnose her condition in order to assess the claim”. 

She said upon her return to Australia, her specialist concluded her hospitalisation was due to fluid overload from sleep apnoea and not due to obesity or vein problems.  

She said she did not disclose that she was obese because the insurer had not asked questions relating to her weight or height in the policy application and she was unaware it needed to be listed. 

The Australian Financial Complaints Authority accepts obesity “may not ordinarily fall under an existing medical condition that the complainant would be aware of”. But it says the woman should have informed the insurer about it given her medical history.

“In this matter, the complainant’s morbid obesity had been a condition that she had repeatedly received treatment for over the years ... [and] led to the complainant suffering from a number of subsequent health conditions,” the authority’s ombudsman said.

“These health conditions were often severe and at times required medication and hospitalisation. On that basis, I am not satisfied a reasonable person in the complainant’s circumstances would not have been aware of her obesity.” 

The decision allows Zurich to decline the claim and does not require it to pay compensation for its handling of the matter. 

“While I sympathise with the complainant for her loss, the outcome is fair because the complainant has not established a claimable loss under the policy,” the ombudsman said.  

Click here for the ruling.