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Claimant wins in dispute against Westpac over coma definition

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The Australian Financial Complaints Authority (AFCA) has ruled in favour of a complainant whose claim for benefit payment was rejected in March last year by Westpac Life Insurance.

Westpac Life says the claimant, who was diagnosed with necrotising fasciitis to his right arm in 2018, did not satisfy the definition of coma as was stated in his policy, which provides for a “Living Plus” benefit if the condition was met.

The claimant had lodged his claim three months after he went into an induced coma at a hospital in July 2018. Medical evidence submitted showed the claimant suffered secondary severe sepsis as a result of the fasciitis, and had multiple organ failure.

He also required several debriding procedures during his hospital stay, plus a skin graft to his left upper thigh to support the recovery of his right arm.

When Westpac assessed his claim, it decided the claimant did not meet the requirement for a Glasgow Coma Scale of 6 or less, which is essential for a benefit to be paid out under the policy definition.

The insurer says the claimant’s hospital admission records mentioned nothing about whether he was in a state of unconsciousness that fell under the Glasgow metrics and required at least three straight days of the use of a life support system.

Westpac also said the doctor who treated him was not able to state if his patient met the coma definition as was set out in his policy.

But AFCA disagreed, ruling there were several problems with the insurer’s arguments.

“There is no dispute that the complainant was in an induced coma, requiring life support for three consecutive days,” AFCA said. “The only issue really in dispute is whether the complainant’s condition resulted in a Glasgow Coma Score of 6 or less, persisting continuously.

“The covered condition is coma, not brain injury. The policy definition of coma does not require an acute brain injury. The fact that the complainant did not suffer an acute brain injury does not disentitle him to the benefit.”

AFCA ordered Westpac to pay the claimant the benefit he had lodged for plus interest from January 16 last year to the date payment is made.

Click here for the determination.