Battered traveller loses dispute over root cause of missing teeth
An assault victim has lost his bid for a dental treatment payout because the teeth he lost in an attack by five men were found to have pre-existing problems.
The claimant was in Lisbon on a business trip in October 2022 when he was beaten and robbed after mistakenly entering a vehicle he believed was his Uber car.
He said he suffered significant facial injuries and lost several teeth, which made it difficult to chew.
The victim, who was insured through his employer’s business travel policy, lodged a claim about a year later for $67,160 of dental treatment, plus loss of and damage to personal items.
Insurer Chubb agreed to cover most personal items but said long-term neglect and previous opioid medication left the man’s teeth in a poor state, and it would not pay for the treatment.
The policy benefit concerning dental losses required injuries to be caused by “an accident which occurs independently of any illness or other cause”.
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Chubb said medical records showed the man had 10 teeth missing before the incident and his treating dentist determined the subsequent losses were “more likely due to long-term neglect” than the assault.
The insurer also referred to another doctor, who observed most of the claimant’s teeth had been “heavily compromised”.
“It is likely that these teeth would have fractured during normal chewing function at some point in the very near future. However, the assault has hastened their demise,” the doctor said.
In a dispute ruling, the Australian Financial Complaints Authority says there is no evidence the “loss of teeth was solely and directly as a result of the assault and independent of any other cause as required to meet the definition of bodily injury”.
It also notes that the policy states customers seeking cover for medical care in Australia should have first sought and received treatment while overseas, which the complainant did not do.
Chubb was also entitled to decline the man’s claim for a stolen gold chain worth $5000, AFCA says.
The insurer requested further information on the item’s value and date of loss, but the insured did not respond to these.
See the ruling here.
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