CR340
Interpretation
Definition of diabetes.
Background
Mrs M had a policy that provided cover inter alia for diabetes. The diabetes benefit was set out as follows in the contract:
“Diabetes
Diagnosis by a paediatrician, endocrinologist or physician specialist of
Type 1 diabetes.
10% of the Cover Amount is payable.”
On 08.10.2009 she visited a specialist physician and presented “with a 2-week
history of severe upper abdominal pain, nausea and vomiting.” He assessed her
condition as:
“1. Acute pancreatitis secondary to hyperlipedemia
2. Diabetes mellitus.”
Based on the diagnosis Mrs M submitted a claim to the insurer which the insurer declined because –
“The doctor has clearly stated that this is secondary to pancreatic failure which in itself is difficult to understand seeing this was an isolated case of acute pancreatitis.
Be that as it may diabetes that develops as a result of pancreatic failure or disease is known as Type 3 (c) Diabetes and seeing our product only covers Type 1, this is a decline.”
Assessment
We referred the matter to an independent medical consultant for an opinion and he stated the following in his report:
“Dr P reported that Mrs M presented on 08/10.2009 with a 2 week history of acute abdominal pain. A diagnosis of acute pancreatitits was made, and this was ascribed to hyperlipidaemia; her serum triglycerides were markedly raised. She was also found to have diabetes, evidently not previously diagnosed.
She was discharged on medication to control hyperlipidaemia, and oral anti-diabetic agents. Dr. P’s diagnoses were:
1. Acute pancreatitis secondary to hyperlipidaemia
2. Diabetes mellitus.
A note written in April 2010 by Dr P states that ‘Mrs M is presently Type 1 Diabetic – insulin dependent. This is secondary to pancreatic failure following pancreatitis related to hyperlipidaemia.’
A follow up report by Dr P on 06/07/2010 indicates that Insulin had been added to oral therapy…
Evaluation
It would appear that Dr P decided that Mrs M’s dependence on insulin to control her diabetes, had enabled him to classify her as a type 1 Diabetic.
Though this approach may be understandable in the case of a 36 year old patient presenting de novo with insulin dependent diabetes, an attack of acute pancreatitis preceding the initial diagnosis of diabetes would warrant a diagnosis of diabetes secondary to pancreatic disease.
She should thus fall in the least common category, Type 111 Diabetes which is secondary to various underlying disorders. It is likely that, had a low C-peptide level been a diagnostic definer of Type 1 Diabetes, she might have qualified in terms of the contract, as loss of insulin producing beta cells is common to both Type 1 and Type 111 diabetes.
This is an unusual variation on the recurrent problem arising from the insurer’s definition of Type 1 Diabetes, which implies that pronouncement by, inter alia, ‘A Physician’ is an accepted criterion. Evidently Dr P considers Insulin dependence to be a ‘working’ diagnosis, without resorting to further investigation. As already stated, she is likely to have a significantly reduced C-peptide level. However, I would consider the insurer to have been justified in declining this claim in terms of the contract.
Apart from the clause related to diabetes, it is not clear whether the insurer should be unable to respond to this claim for a major and life changing illness affecting a relatively young woman. At age 35 years she was found to have pronounced hyperlipidaemia causing acute pancreatitis followed by diabetes.”
A copy of the report was provided to the insurer.
Result
Without admission of liability the insurer decided to make an ex gratia payment, in an amount equal to what would have been payable had the insurer admitted the claim under the Diabetes benefit.
HE
February 2013
