CR260

Exception – exclusion clause – event arising from pregnancy – interpretation.

BACKGROUND

In a health policy the complainant was covered for hospitalisation costs. One of the exclusions stipulated that:

“No Benefit will be payable if an insured Event is a result of, by, for or from …abortion, pregnancy or any condition arising therefrom.”

When she was seven months pregnant the complainant contracted pyelonephritis, a genitourinary tract infection, was hospitalised as a result, and claimed the benefit. Accompanying her claim was the usual medical certificate required to be completed on the insurer’s form, in which her gynaecologist stated, in answer to specific questions, that the hospitalisation had been for “a urinary tract infection in pregnancy”, and that the reason for the hospitalisation had been “pregnancy”. Based thereon, and relying on the exclusion clause, the insurer repudiated the claim.

DISCUSSION

When the complainant then lodged a complaint with the office it was accompanied by a report by the same gynaecologist in which he said that “…while the condition may be more common in pregnancy it can also occur outside pregnancy”. The office extracted an article on pyelonephritis, which it sent to the insurer, and in which it was said that the condition is one that occurs both in men and women, that the risk may be increased during pregnancy but is also increased in many other situations.

The office pointed out to the insurer that in these circumstances the condition had not necessarily been the result of the complainant’s pregnancy. It added that the insurer bears the onus when relying on an exclusion, and that unless it could show that in the complainant’s case her pyelonephritis had arisen from the pregnancy, in other words that there was a causal link between the pregnancy and the pyelonephritis, the exclusion clause would be inapplicable.

CONCLUSION

The insurer, apparently being unable to provide the proof concerned, agreed to pay the benefit.

SM
January 2009