CR348

Exceptions

Exclusion clause – Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequence thereof

Background

The insurer in this instance is not a member of the Association of Savings and Investment SA (ASISA) and, as such, it is not bound by ASISA’s HIV protocol which provides that no member office may use HIV/AIDS exclusion clauses for new business with effect from 1 January 2005.

In a health policy the complainant was covered for hospitalization costs. One of the exclusions in his contract stipulated that:

“No Benefit will be payable if an Insured Event is as a result of, by, for or from:

…

Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequences thereof”.

The complainant was hospitalized as a result of Varicella Chicken Pox for five days and claimed the benefit. The insurer assessed the claim but declined it “based on the fact that the hospitalisation was related to HIV”.

Discussion

We referred the matter to a medical consultant for an opinion and he stated the following in his report:

“It is a well-known fact that even healthy adults get chickenpox in a much more severe form than children, and that complications like encephalitis, myocarditis, Reye syndrome, and transient arthritis are common. In this case, it seems that the claimant had encephalitis and herpes zoster as complications. It is important to realise that these complications are not restricted to HIV patients, and that encephalitis warrant in-hospital treatment and observation even in healthy subjects. And in these cases it is not uncommon to be hospitalised for 4 to 5 days, depending on individual factors.

The onus of proof in this case lies with the insurer, and in my opinion they have not produced sufficient evidence to warrant refusing to pay the claim. They would have to prove that the claimant was in Aids clinical stage 4 at the time, with a CD-4 count below 200. This could indicate that a significantly impaired immune system could have contributed to the severity of the disease and a longer recovery time.

With the information presented, this seems like a valid reason for in-hospital treatment for the time specified. The repudiation of the claim is not supported by the medical information supplied.”

A copy of the report was provided to the insurer.

Result

The insurer agreed to pay the claim.

HE
February 2013

CR348

Exclusions

Exclusion clause – Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequence thereof

Background

The insurer in this instance is not a member of the Association of Savings and Investment SA (ASISA) and, as such, it is not bound by ASISA’s HIV protocol which provides that no member office may use HIV/AIDS exclusion clauses for new business with effect from 1 January 2005.

In a health policy the complainant was covered for hospitalization costs. One of the exclusions in his contract stipulated that:

“No Benefit will be payable if an Insured Event is as a result of, by, for or from:

…

Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequences thereof”.

The complainant was hospitalized as a result of Varicella Chicken Pox for five days and claimed the benefit. The insurer assessed the claim but declined it “based on the fact that the hospitalisation was related to HIV”.

Discussion

We referred the matter to a medical consultant for an opinion and he stated the following in his report:

“It is a well-known fact that even healthy adults get chickenpox in a much more severe form than children, and that complications like encephalitis, myocarditis, Reye syndrome, and transient arthritis are common. In this case, it seems that the claimant had encephalitis and herpes zoster as complications. It is important to realise that these complications are not restricted to HIV patients, and that encephalitis warrant in-hospital treatment and observation even in healthy subjects. And in these cases it is not uncommon to be hospitalised for 4 to 5 days, depending on individual factors.

The onus of proof in this case lies with the insurer, and in my opinion they have not produced sufficient evidence to warrant refusing to pay the claim. They would have to prove that the claimant was in Aids clinical stage 4 at the time, with a CD-4 count below 200. This could indicate that a significantly impaired immune system could have contributed to the severity of the disease and a longer recovery time.

With the information presented, this seems like a valid reason for in-hospital treatment for the time specified. The repudiation of the claim is not supported by the medical information supplied.”

A copy of the report was provided to the insurer.

Result

The insurer agreed to pay the claim.

HE
February 2013

CR348

Waiting periods

Exclusion clause – Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequence thereof

Background

The insurer in this instance is not a member of the Association of Savings and Investment SA (ASISA) and, as such, it is not bound by ASISA’s HIV protocol which provides that no member office may use HIV/AIDS exclusion clauses for new business with effect from 1 January 2005.

In a health policy the complainant was covered for hospitalization costs. One of the exclusions in his contract stipulated that:

“No Benefit will be payable if an Insured Event is as a result of, by, for or from:

…

Acquired Immune Deficiency Syndrome (AIDS) or HIV infection, including all phases and consequences thereof”.

The complainant was hospitalized as a result of Varicella Chicken Pox for five days and claimed the benefit. The insurer assessed the claim but declined it “based on the fact that the hospitalisation was related to HIV”.

Discussion

We referred the matter to a medical consultant for an opinion and he stated the following in his report:

“It is a well-known fact that even healthy adults get chickenpox in a much more severe form than children, and that complications like encephalitis, myocarditis, Reye syndrome, and transient arthritis are common. In this case, it seems that the claimant had encephalitis and herpes zoster as complications. It is important to realise that these complications are not restricted to HIV patients, and that encephalitis warrant in-hospital treatment and observation even in healthy subjects. And in these cases it is not uncommon to be hospitalised for 4 to 5 days, depending on individual factors.

The onus of proof in this case lies with the insurer, and in my opinion they have not produced sufficient evidence to warrant refusing to pay the claim. They would have to prove that the claimant was in Aids clinical stage 4 at the time, with a CD-4 count below 200. This could indicate that a significantly impaired immune system could have contributed to the severity of the disease and a longer recovery time.

With the information presented, this seems like a valid reason for in-hospital treatment for the time specified. The repudiation of the claim is not supported by the medical information supplied.”

A copy of the report was provided to the insurer.

Result

The insurer agreed to pay the claim.

HE
February 2013