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Case Study Pre-existing conditions are excluded from medical insurance

The insured was admitted to hospital for abdominal pain and blood in stool 10 days after she has effected a hospitalization policy. Histopathology report confirmed a colon tumour measuring about 5 cm.

The insurer revealed that the insured had consulted for rectal bleeding with hard stool 15 months prior to her application for insurance. Furthermore, based on the size of the tumour, the insurer was of the view that the tumour could not have developed within 10 days. As such, the insurer rejected her hospitalization claim on the basis of pre-existing condition.

The insured alleged that her consultation for rectal bleeding some 15 months ago was only due to haemorrhoid and she had fully recovered. She believed that the insurer was unreasonable to decline her hospitalization claim as the diagnosis of carcinoma of colon was made 10 days after the policy inception date.

Although the available information failed to indicate the exact onset date of the insured’s colon cancer, the Complaints Panel, having taken into account the size of the colon tumour, was of the view that the tumour might take some time to grow until it was revealed by colonoscopy.

Given the diagnosis of carcinoma of colon was made only 10 days after the policy was effected, the Complaints Panel was of the view that tumour of that size could not have developed within less than 10 days after the commencement date of the policy. As the policy excludes any illness or injury that commenced or presented signs and symptoms prior to the policy commencement date, the Complaints Panel endorsed the insurer’s decision to reject the hospitalization claim.

Remarks: a problem often met in applying the “pre-existing condition” exclusion is that it could be difficult to ascertain the exact onset date of a condition.