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Claimant loses $25,000 battle after overseas cancer diagnosis

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Zurich Australia has denied a claim from a travel insurance customer who was diagnosed with prostate cancer while overseas.

The insured had surgery to remove his prostate while travelling in May 2020, and claimed $25,000 for medical and accommodation expenses.

But Zurich decided that the condition was existing, and the expenses are excluded under the policy.

The customer took his case to the Australian Financial Complaints Authority (AFCA), but the ombudsman agreed with the insurer’s interpretation.

The policy contains a lengthy definition of what an “existing condition” is, and this does not rely on a diagnosis having been made.

The disease, illness or condition could be showing signs or symptoms before a medical opinion has been sought, or it could be under investigation or pending test results.

Medical information shows that the complainant had a prostate-specific antigen (PSA) blood test, to screen for prostate cancer, in late 2018.

PSA levels were elevated so he had an MRI which showed a 5mm “well-defined hypointense lesion” which indicated a cancer risk of about 20%.

However, in March 2019 the PSA level dropped and a urologist recommended holding off on biopsies.

While travelling, the complainant sought medical advice after having trouble urinating, and a biopsy confirmed cancer.

The complainant says he was told by the insurer that the prostatectomy was covered and that he would not have gone ahead with it if he’d known that it wasn’t.

But AFCA says there is no evidence to support this.

“The complainant says he did not have an existing medical condition on 6 December 2019. He says he had lower PSA levels immediately prior to entering into the travel insurance policy,” AFCA says.

“While the complainant had not been diagnosed with prostate cancer at policy inception on 6 December 2019, I am satisfied that the circumstances of his condition satisfy the policy condition for ‘existing medical condition’.

“This is because at 6 December 2019, it was clear that the complainant had a risk of prostate cancer and this condition was under investigation.”

Click here for the full ruling.