Claim case sharing
Why will a claim for cancer discovered 10 days after the policy effective date be declined?
Mr. Chan was admitted to hospital with abdominal pain and blood in his stool 10 days after he took out a hospitalisation policy. A histopathology report confirmed a colon tumour measuring about 5cm and the diagnosis was carcinoma of the colon.
Mr. Chan filed his insurance claim for his medical expenses, but it was rejected by his insurer. Why did Mr. Chan’s insurer reject his claim?
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 his hospitalisation claim on the grounds that the tumour was a pre-existing condition.
Mr. Chan believed that the insurer was unreasonable to decline his hospitalisation claim as the diagnosis of carcinoma of the colon was made 10 days after the policy effective date.
Although the available information failed to indicate the exact onset date of Mr. Chan’s colon cancer, given that the diagnosis of carcinoma of the colon was made only 10 days after the policy was effected, the Insurance Claims Complaints Panel was of the view that a tumour of that size could not have developed within 10 days after the commencement date of the policy. As the policy excludes any illness or injury that started or presented signs and symptoms prior to the policy commencement date, the Complaints Panel endorsed the insurer's decision in rejecting the hospitalisation claim.
Pre-existing conditions are generally excluded by most medical insurance policies. Insurance companies will judge each individual case carefully based on the relevant medical report to determine whether there is sufficient evidence to rule that a condition is pre-existing. In the next issue, we will discuss some basic areas for consideration in determining a pre-existing condition.