CR241

Dread disease

Complainant claiming for dread disease benefit on grounds of cancer – policy excluding “(a) all skin cancers, and (b) cancer–in-situ, including all melanomas-in-situ”- established that, while complainant’s was not a cancer-in-situ or a melanoma-in-situ, the tumour had not spread beyond the skin and therefore remained a skin cancer; insurer’s liability excluded

Background

The complainant’s policy provided for the payment of benefits in the case of so-called “personal catastrophes”, of which cancer was one. It was described as follows:

“Cancer – a disease manifested by the presence of a malignant tumour characterised by the uncontrolled growth and spread of malignant cells, and the invasion of tissue. The term “cancer” also includes leukaemia and Hodgkin’s Disease but excludes:
(a) all skin cancers
(b) cancer-in-situ, including melanoma-in-situ”.

Medical reports indicated that the complainant had a “changing mole” on his right leg. A biopsy showed that it was “an infiltrating superficial spreading melanoma”, measured as “Clark’s Level III Breslow 0,32mm”. The tumour was excised. The doctor reported that there was no residual tumour, and the area healed without complications.

The insurer repudiated the complainant’s claim for a benefit on the grounds that such cancer, a skin cancer, was an excluded type in terms of the policy provision.

Discussion

We agreed with the insurer that, as the cancer was a skin cancer, it was an excluded condition, and the insurer was not liable to pay the claim. We furthermore advised the complainant that his melanoma also appeared still to be in-situ. We referred to clinical descriptions of the stages of melanoma published by the Skin Cancer Foundation, which indicated that his melanoma was at Stage 1a – the tumour was less than 1.0mm (regarded as a very thin tumour) and had not spread to any other part of the body beyond the skin.

The complainant took issue with this. He claimed that, because his was one that was described as an infiltrating superficial spreading melanoma, his cancer was not one in-situ and that it was therefore not excluded. He backed his assertion with a letter from a dermatologist to the effect that, as the melanoma had infiltrated the skin, rather than remaining on the outer layer (epidermis), it was not a melanoma-in-situ. Based thereon the complainant maintained that the express addition to the definition in clause (b) of a melanoma-in-situ as part of the exclusion could only mean that a melanoma that is not in-situ was not intended to be excluded. He also argued that melanomas are not normal skin cancers, and that this was apparently why they were mentioned as a separate case in the policy.

At that stage we sought the advice of an independent medical expert, who agreed that the melanoma was not in-situ, as it had spread from its site of origin into neighbouring epidermal tissue. He added, however, that as it had not spread beyond the basement layer of the dermis, it was confined to the skin and was therefore still a skin cancer.

We therefore stood by our initial ruling that the cancer, being a skin cancer, was excluded. We accepted that because all skin cancers were excluded in terms of clause (a), it was unnecessary for the policy also to have mentioned a melanoma-in-situ as an exclusion in clause (b). While it was certainly a tautologous addition, however, it made no difference and would not mean that the exclusion in (a) did not apply to the complainant’s melanoma.

Result

The insurer’s repudiation of the claim was upheld.