Interpretation – payment of a cancer claim dependent upon the opinion of the company’s Chief Medical Officer.
Background
The policy provided a death benefit and a dread disease benefit. The two benefits were free standing, that is to say that dread disease benefit was not an acceleration of the death sum assured. The complainant who was a 50 year old female was seriously ill, suffering from Acute Myeloblastic Leukaemia. The prognosis was poor and it was quite likely that the insurance company would be paying both a life claim and a dread disease claim in the comparatively near future.
The definition of “Life Threatening Cancer” which featured in the contract read as follows:
“A Malignant tumour supported by histological diagnosis showing spread of malignant cells with invasion and destruction of normal tissue for which interventionist treatment or surgery is necessary.
The staging of the cancer will use an appropriate medically acceptable staging system acceptable to the Company’s Chief Medical Officer. (our italics)
Stage 1 20%
Stage 2 50%
Stage 3 75%
Stage 4 100%
Non-Life threatening cancers: 5%
• “Prostate Cancer, histologically described as T1 in the tumour, Nodes < Metastasis(TNM) classification.
• Papillary Micro-carcinomas of the thyroid of bladder.
Specific Exclusions
• All skin cancers including malignant melanomas of less than 1.5mm maximum thickness using the Breslow method unless there is evidence of metastases.
• Stage 1 Hodgkins Disease
• All conditions histologically described as pre-malignant as cancer in-situ including CIN 1 CIN 2 and CIN 3 of the cervix
• Kaposi sarcoma and other AIDS related tumours
• Chronic Lymphocytic leukaemia”
The insurance company’s Chief Medical Officer regarded the cancer as a Stage 2 and 50% of the benefit was paid. The complainant was of the view that her condition was such that a 100% benefit was justified.
Assessment
The contract specified that the benefits paid depended on the stage of cancer ranging from Stage 1 to Stage 4. These stages are not defined which means that conventional cancer staging is used. Distant metastases, regardless of the site of origin of the tumour indicate a Stage 4 disease. Various hematologists whose opinions were obtained also expressed the view that Acute Myeloblastic Leukaemia was a Stage 4 disease.
The insurance company’s Chief Medical Officer, whose opinion was decisive so far as the insurance company was concerned, took the view that there was a possibility of complete remission following aggressive therapy involving ablation of the bone marrow and marrow transplantation. But in terms of the policy provision this was not a factor. As defined in the contract the complainant was suffering from a Stage 4 cancer and qualified for 100 percent benefit.
Result
The complaint was upheld and the insurance company agreed to pay 100 percent benefit.
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