Claim case sharing
The Principle of Proximate Cause in Medical Claims
Ms. Ho was admitted to hospital with lower back pain last month and was diagnosed with a prolapsed intervertebral disc which required a surgical operation to be performed. Unluckily, Ms. Ho's abdominal aorta wall was punctured during the operation and she went into shock with internal bleeding. As a matter of urgency, she was transferred to another hospital to undergo a repair operation on her blood vessel.
Ms. Ho admitted that her operation for treatment of a prolapsed intervertebral disc was a pre-existing condition which should be excluded from the policy. When she was discharged from hospital, she only submitted a claim to her medical insurance company for reimbursement of medical expenses incurred during the second operation.
However, the insurance company rejected her claim. Why was Ms. Ho's second hospitalisation not covered by her medical insurance policy?
Ms. Ho thought that her emergency confinement for the second operation, the aim of which was to remedy the blood vessel puncture that occurred during the first operation, was entirely unforeseen and unexpected. As a result, she believed that her insurance company should reimburse her medical expenses incurred for the second operation.
The second operation for remedying the puncture was caused by a potential operation risk arising from the first operation for her prolapsed intervertebral disc. If the first operation had not taken place, the second operation would not have been necessary. As the proximate cause of the second operation was related to the first operation and the first operation was excluded from Ms. Ho's medical policy, her insurance company was not liable for Ms. Ho's hospitalisation claim.