Posts in category: AIDS/HIV

CR348

Exceptions

Exclusion clause – Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequence thereof

Background

The insurer in this instance is not a member of the Association of Savings and Investment SA (ASISA) and, as such, it is not bound by ASISA’s HIV protocol which provides that no member office may use HIV/AIDS exclusion clauses for new business with effect from 1 January 2005.

In a health policy the complainant was covered for hospitalization costs. One of the exclusions in his contract stipulated that:

“No Benefit will be payable if an Insured Event is as a result of, by, for or from:

…

Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequences thereof”.

The complainant was hospitalized as a result of Varicella Chicken Pox for five days and claimed the benefit. The insurer assessed the claim but declined it “based on the fact that the hospitalisation was related to HIV”.

Discussion

We referred the matter to a medical consultant for an opinion and he stated the following in his report:

“It is a well-known fact that even healthy adults get chickenpox in a much more severe form than children, and that complications like encephalitis, myocarditis, Reye syndrome, and transient arthritis are common. In this case, it seems that the claimant had encephalitis and herpes zoster as complications. It is important to realise that these complications are not restricted to HIV patients, and that encephalitis warrant in-hospital treatment and observation even in healthy subjects. And in these cases it is not uncommon to be hospitalised for 4 to 5 days, depending on individual factors.

The onus of proof in this case lies with the insurer, and in my opinion they have not produced sufficient evidence to warrant refusing to pay the claim. They would have to prove that the claimant was in Aids clinical stage 4 at the time, with a CD-4 count below 200. This could indicate that a significantly impaired immune system could have contributed to the severity of the disease and a longer recovery time.

With the information presented, this seems like a valid reason for in-hospital treatment for the time specified. The repudiation of the claim is not supported by the medical information supplied.”

A copy of the report was provided to the insurer.

Result

The insurer agreed to pay the claim.

HE
February 2013

CR348

Exclusions

Exclusion clause – Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequence thereof

Background

The insurer in this instance is not a member of the Association of Savings and Investment SA (ASISA) and, as such, it is not bound by ASISA’s HIV protocol which provides that no member office may use HIV/AIDS exclusion clauses for new business with effect from 1 January 2005.

In a health policy the complainant was covered for hospitalization costs. One of the exclusions in his contract stipulated that:

“No Benefit will be payable if an Insured Event is as a result of, by, for or from:

…

Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequences thereof”.

The complainant was hospitalized as a result of Varicella Chicken Pox for five days and claimed the benefit. The insurer assessed the claim but declined it “based on the fact that the hospitalisation was related to HIV”.

Discussion

We referred the matter to a medical consultant for an opinion and he stated the following in his report:

“It is a well-known fact that even healthy adults get chickenpox in a much more severe form than children, and that complications like encephalitis, myocarditis, Reye syndrome, and transient arthritis are common. In this case, it seems that the claimant had encephalitis and herpes zoster as complications. It is important to realise that these complications are not restricted to HIV patients, and that encephalitis warrant in-hospital treatment and observation even in healthy subjects. And in these cases it is not uncommon to be hospitalised for 4 to 5 days, depending on individual factors.

The onus of proof in this case lies with the insurer, and in my opinion they have not produced sufficient evidence to warrant refusing to pay the claim. They would have to prove that the claimant was in Aids clinical stage 4 at the time, with a CD-4 count below 200. This could indicate that a significantly impaired immune system could have contributed to the severity of the disease and a longer recovery time.

With the information presented, this seems like a valid reason for in-hospital treatment for the time specified. The repudiation of the claim is not supported by the medical information supplied.”

A copy of the report was provided to the insurer.

Result

The insurer agreed to pay the claim.

HE
February 2013

CR348

Waiting periods

Exclusion clause – Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequence thereof

Background

The insurer in this instance is not a member of the Association of Savings and Investment SA (ASISA) and, as such, it is not bound by ASISA’s HIV protocol which provides that no member office may use HIV/AIDS exclusion clauses for new business with effect from 1 January 2005.

In a health policy the complainant was covered for hospitalization costs. One of the exclusions in his contract stipulated that:

“No Benefit will be payable if an Insured Event is as a result of, by, for or from:

…

Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequences thereof”.

The complainant was hospitalized as a result of Varicella Chicken Pox for five days and claimed the benefit. The insurer assessed the claim but declined it “based on the fact that the hospitalisation was related to HIV”.

Discussion

We referred the matter to a medical consultant for an opinion and he stated the following in his report:

“It is a well-known fact that even healthy adults get chickenpox in a much more severe form than children, and that complications like encephalitis, myocarditis, Reye syndrome, and transient arthritis are common. In this case, it seems that the claimant had encephalitis and herpes zoster as complications. It is important to realise that these complications are not restricted to HIV patients, and that encephalitis warrant in-hospital treatment and observation even in healthy subjects. And in these cases it is not uncommon to be hospitalised for 4 to 5 days, depending on individual factors.

The onus of proof in this case lies with the insurer, and in my opinion they have not produced sufficient evidence to warrant refusing to pay the claim. They would have to prove that the claimant was in Aids clinical stage 4 at the time, with a CD-4 count below 200. This could indicate that a significantly impaired immune system could have contributed to the severity of the disease and a longer recovery time.

With the information presented, this seems like a valid reason for in-hospital treatment for the time specified. The repudiation of the claim is not supported by the medical information supplied.”

A copy of the report was provided to the insurer.

Result

The insurer agreed to pay the claim.

HE
February 2013

CR183

Exclusion clause – HIV diagnosed after application date but prior to the commencement date.

Background

The life insured applied for a policy on 4 May 2004. On 14 June 2004 the life insured was diagnosed as being HIV positive. The commencement date of the policy was 1 July 2004. On 29 November 2004 he died as a result of pulmonary embolism. The insurer declined the claim as the HIV diagnosis:

“is before the inception date. It is a pre-existing medical condition and is therefore excluded in terms of the policy provisions.”

The policy provided as follows:

”In the event of there being any claim under this benefit within 24 (twenty four) months from the commencement date or most recent date of reinstatement or any increase in cover (other than inflation growth), following the life assured’s death which is in [the insurer’s] opinion, based on medical evidence supplied by the life assured’s medical practitioner at the time of his death, due to or arising from a medical condition of any nature whatsoever from which the life assured was suffering at the time of his application for this benefit, no payment shall become due under this benefit, which shall be void and all premiums paid in respect thereof shall be forfeited.”

Discussion

We took the view that “the time of his application for this benefit” was 4 May 2004 (the date of proposal). According to the medical information submitted in support of the claim, the blood test was done on 14 June 2004. This was after the time of “his application for this benefit”. We suggested to the insurer that the claim be paid, as the life assured’s medical practitioner did not provide any medical evidence indicating that the life assured was suffering from a medical condition that contributed to his death at the date of application for the benefit.

Result

The claim was settled.

HE
November 2006