Circumstantial evidence points to a pre-existing condition, Osti finds

Circumstantial evidence points to a pre-existing condition, Osti finds

The Ombudsman for Short-term Insurance (Osti) has upheld an insurer’s decision to reject a travel insurance claim despite a medical specialist stating that the policyholder might not have been suffering from a pre-existing condition.

The insured had a small sore in his nose that healed “well before” he and his wife departed for Thailand on 8 October 2018.

While on the flight to Thailand, the insured noticed that he had a blind pimple inside his nostril.

By 12 October, after arriving in Thailand, the pimple had escalated into a boil.

The next day, the insured went to a doctor. The insured told the doctor about the small sore in his nose two weeks previously. The doctor referred him to a hospital for treatment by a specialist.

The insured submitted a claim for medical fees and curtailment.

The insurer rejected the claim on the ground that it arose, directly or indirectly, as a result of a pre-existing medical condition that was not covered.

The policy defined a pre-existing medical condition as: “Any past or current medical condition that has given rise to symptoms or for which any form of treatment or prescribed medication, medical consultation, investigation or follow-up/check-up has been required or received during six months prior to the commencement of cover under this policy and/or prior to any trip …”

The insured flew back to South Africa on 14 October and was treated by a specialist the following day. The infection stopped almost immediately after the specialist incised and drained a small abscess in the anterior of the right nostril.

In a letter, the specialist stated, “it is not impossible that the infection that started in Thailand was a different or a second one, and the initial complaint is, therefore, not necessarily the start of what he had in Thailand”.

The Osti’s findings

The Osti said it was noteworthy that the policyholder had regarded the sore in his nose two weeks before his departure as being of sufficient relevance to inform the Thai doctor thereof.

The Osti found the South African specialist to have misplaced the expressions “not impossible” and “not necessarily” in consideration of the probabilities. The specialist also did not advance any reasons for the conclusion he reached.

The medical condition that showed “vigorous escalation” in Thailand was, as a matter of probability, the same one that manifested itself as a “nose sore”, with accompanying pain, at or about the end of September 2018. Moreover, on the available evidence, the Osti found it abundantly clear that the insured was aware of those symptoms.

Accordingly, the Osti upheld the insurer’s decision to reject the claim.

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