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Insurance – critical care – claimant unwilling to undergo further tests
In 1999 Mrs J suffered a stroke and subsequently underwent an operation to clip a cerebral artery aneurism. A further aneurism was noted but was not operated upon, and she has remained under observation for this. Mrs J was left with no physical consequences, but did experience a number of neurological deficits such as memory loss and lack of concentration, resulting in her inability to hold down a job or to drive for more than a short distance.
Mrs J held a life and critical care insurance policy with her bank and made a claim under the section providing cover for a critical condition, including stroke, where there is evidence of functional impairment caused by permanent neurological deficit. The bank would not accept her claim on the basis of a medical report by her general practitioner (GP), and insisted on an assessment by a neurologist approved by itself. When obtained, the neurologist’s assessment confirmed the diagnosis of “problems significantly disabling particularly in regard to work”, but the bank would not accept this as evidence of permanent neurological deficit creating functional impairment without further neuropsychological testing. Mrs J was unwilling to undergo further tests because she would be required to travel some distance on two separate occasions for the tests, and she feared that the stress involved would result in further damage to her health. She was supported in this by her GP.
After discussions with the bank I contacted the neurologist, who confirmed his diagnosis and explained that his suggestion of neuropsychological testing was to determine the extent of the cognitive deficit, not its existence. I sent this further report to the bank, and subsequently met with its representative to discuss the case. As a result, although the bank was not convinced that Mrs J met the criteria for a payment under the critical care section of her policy, it agreed to make an ex gratia payment to her of the full amount – $32,000 – that would have been payable under the policy. Mrs J accepted the bank’s offer and her complaint was resolved on that basis.