Is the condition pre-existing?

A complainant joined a private health insurer. Four months after taking out cover, her breast implant ruptured and required removal. When she submitted her claim to her insurer for hospital admission, it was denied on the basis that her insurer considered the breast implant rupture to be a pre-existing condition.

The complainant lodged a complaint with our Office.

Our role was to determine if the Pre-Existing Conditions rule was applied correctly and fairly by the insurer. A pre-existing condition is defined as any ailment, illness or condition where, in the opinion of a medical adviser appointed by the insurer, the signs or symptoms of that condition existed at any time in the period of 6 months before being insured.

We decided to investigate. From the information initially provided by the insurer, it appeared the pre-existing condition rule had been applied correctly. During our investigation, however, it became evident from the insurer’s initial decision that the insurer did not have access to an earlier scan. We suggested the complainant provide these earlier scans to the insurer. The insurer reviewed this additional material and reversed its previous decision.

As a result, the complainant was able to claim her hospital admission benefits with the private health insurer.

2024