A skin cancer survivor seeking a trauma benefit under a TAL life policy has lost a dispute because her tumour was not in an advanced stage.

The woman lodged a claim almost two years ago following removal of melanoma from the arch of her right foot.

TAL declined the claim, saying its policy excluded all skin cancers except melanomas with evidence of ulceration or those with a 1mm or more “Breslow thickness” or a “Clark level 3” or more depth.

For “early-stage melanoma” to be covered, it had to be “characterised by the uncontrollable growth and spread of malignant cells and the invasion and destruction of normal tissue”.

The Australian Financial Complaints Authority says most evidence from several doctors indicated the melanoma was “in situ” and not of 1mm or more Breslow thickness.

“In relation to either definition, there is nothing ambiguous about them. To the contrary, they are both clear. I am not satisfied that the complainant’s condition met all aspects,” an AFCA ombudsman said.

A medical certificate stated the tumour was localised, there was no invasion of adjacent tissue, regional lymph nodes were not involved and there were no distant metastases.

Other reports showed no dermal invasion, features of regression, ulceration or invasion into the dermis or deeper structures, and no destruction of normal tissue.

An oncologist report obtained by TAL stated the lesion was “pre-invasive” with no “invasion and destruction of normal tissue”.

The policyholder argued assessment of malignant melanoma was subjective.

But AFCA says policy definitions clearly set out the requirements. “The insured person must meet the full definition of the specified medical event in order to qualify for a benefit,” the policy stated.

AFCA also notes a lawyer acting for the policyholder added pre-prepared information that did not align with a pathology review before medical certificates were given to doctors.

“Lawyers should not suggest to experts what their opinions should be [or] there will be doubt about the extent to which the opinion is really the doctor’s own opinion, formed free of the lawyer’s influence ... I am not satisfied much weight should be given to the pre-prepared information in the medical certificates,” the ombudsman said.

A request that TAL contribute to the complainant’s legal costs was denied.

See the ruling here.