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OnePath Life backed over accidental death dispute

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OnePath Life’s decision not to pay a $100,000 accidental death benefit for a man who died of an infection affecting his heart has been upheld by the Australian Financial Complaints Authority (AFCA).

The estate of the man argued the policy should respond because an accidental cut on the man’s hand caused a blood infection which ultimately led to his death. It was attributed on the medical certificate to native valve infective endocarditis.

The estate supported its case with photographs of the hand and letters from a general practitioner, and asserted a hospital x-ray was conducted due to staff concerns about swelling of the hand.

But the AFCA adjudicator says the doctor supplying the letters had not treated the patient, while the neurologist and stroke physician directly involved reported the precise source of the infection was not determined.

AFCA says there is no evidence to show the x-ray was related to a laceration, medical records do not refer to any hand laceration and a photograph relied upon by the estate is unclear.

The medical certificate does not mention any injury or external cause involved in the death.

The treating physician goes no further than to say a laceration, if there was one, is a possible means of infection, AFCA says.

“That is not enough,” the adjudicator says. “Unless the laceration or some other accidental injury was the probable means of infection the benefit is not payable.”

The decision is available here.