Exceptions, Exclusions and Waiting Periods CR300
Exclusion clause – causation.
BACKGROUND
The deceased, a 30-year old male, was granted cover under a policy the inception date of which was 14 July 2008. At the same time the policy was ceded to a financial institution to cover his credit agreement with them. He died on 26 February 2009 as a result of natural causes.
A claim was submitted to the insurer, who established that the deceased had died of severe gastro-duodenal bleeding due to peptic ulcer disease, and that he had been HIV/AIDS infected, in fact in an already severely immuno-compromised state at inception of the policy.
In declining the claim the insurer relied on an exclusion clause which read as follows:
“The insurer shall not be obliged to make payment in respect to any condition or event arising directly or indirectly from or traceable to:
…
d) any condition, physical defect, illness, bodily injury or disability which the insured was aware of and received medical advice or treatment for in the twelve months prior to becoming a life insured under this policy, or from 12 months of the reinstatement of any policy.”
The insurer contended that diseases of the gastro-intestinal tract are common among those who are HIV/AIDS infected, and that their reliance on the exclusion clause was therefore justified.
DISCUSSION
We referred the case to a medical practitioner for an opinion and quote as follows from his report:
“The following facts seem undisputed:
• The deceased was HIV positive prior to inception date of the policy.
• The deceased was aware of this diagnosis.
• With a CD-count of 134 one week prior to inception date, it is fair to conclude that the deceased was in stage IV clinical AIDS.
• The cause of death was haematemesis (severe gastro-deodenal bleeding) due to peptic ulcer disease.
The problematic part is the causal link between Aids and peptic ulcer disease. The typical gastro-intestinal problems suffered by Aids patients, are esophageal- and colonic infections, with chronic diarrhoea. I am not aware that Aids patients have an increased incidence or more severe forms of peptic ulcer disease.
In order to come to an evidence-based decision, I have done a comprehensive literature research on this topic.
I have attached copies of the two most relevant studies for your information, the most important parts of which I have underlined. Both studies concur that there is no increased prevalence of peptic ulcer disease in Aids patients. In fact, Helicobacter pylori ulcers, which are by far the commonest cause of peptic ulcers, have a lower prevalence in Aids patients than in healthy patients.
I therefore have to conclude that one cannot prove a direct or indirect causal effect between the pre-existing Aids, and the cause of death, i.e. peptic ulcer disease with haematemesis.
We also do not have evidence of other significant co-morbidities like opportunistic infections which may have been present at the time of death.
Therefore, with the evidence as presented, I would advise that the insurer reconsiders its decision to repudiate the claim. ”
CONCLUSION
When we provided a copy of the report to the insurer, it settled the claim together with interest.
HE
March 2011
