CR161

A cancer claim rejected

Background

The contract featured a specified ‘cancer benefit’ catering for female cancers (cervical cancer, genito-urinary cancer or breast cancer) and male cancers (prostate and testicular cancer). “Cancer” was defined as “…a disease that is manifested by the presence of a malignant tumour, characterised by the uncontrolled growth and spread of malignant cells and the invasion of normal surrounding tissue.”

The complainant, a female, suffered from endometriosis and submitted a claim under the policy contending that endometriosis is analogous to cancer. The insurance company declined the claim on the grounds that endometriosis was not considered to be malignant.

Assessment

Although one has sympathy with the policyholder in her contention that endometriosis may have growth potential similar to cancer cells, this cannot be construed as a basis for classifying it as a cancerous condition. Essential to cancer is the fact that the cancerous cells are not normal tissue cells, but have histologically recognisable characteristics and are largely, if not totally, autonomous. Furthermore, although endometriosis may result in much pain or discomfort, it has a very different prognosis to most forms of cancer.

The contract offered to the policyholder clearly defines the customary accepted insurance criteria for ‘Cancer’, the essence being “uncontrolled growth and spread of malignant cells”. Endometrial cells are not malignant cells but normal uterine cells in extra-uterine sites. The histologists’ report came to the emphatic conclusion “There is no evidence of malignancy” and this reflects the current clinical and academic classification of endometriosis as a non-cancerous condition.

Result

The complaint was not upheld.

DM
April 2006