Hospitalised tourist covered after winning pre-existing condition dispute

An overseas traveller who was hospitalised for days to treat inflamed intestines will have his claim paid after its denial was overturned by an Australian Financial Complaints Authority (AFCA) ruling.

The complainant sought to have his travel policy cover his medical expenses and flight and accommodation costs.

He had been admitted to a hospital in Greece on August 31 last year and was discharged four days later before flying back to Australia.

Zurich Australia denied the man’s claim, saying the policy had exclusions against costs associated with existing medical conditions (EMC). It said the claimant’s illness was related to diverticulitis, which he was treated for in the 12 months before the claim.

The overseas doctor, referred to as Dr ZN, treated the complainant after his symptoms of abdominal pain and cramping worsened. The doctor arranged blood tests that revealed severe inflammation of the large intestine, prompting him to admit the traveller to the hospital.

Further testing showed swelling in the man’s colon, soft tissue inflammation and the formation of small pouches in his intestine – known as diverticula. The inflammation or infection of these pouches is called diverticulitis.

A radiology report from a CT scan said “the findings could represent diverticulitis” but did not rule out that it could have been another type of colitis. Dr ZN considered undertaking a colonoscopy but could not because of significant swelling.

After he was discharged from the hospital, the traveller intended to return to Australia. Due to various flight cancellations, he was forced to fly with a different airline, resulting in additional airfare and accommodation costs.

Zurich submitted to AFCA the man’s patient history from his General Practitioner, which confirmed he had diverticulitis flare-ups in August 2019 and April 2020.

The insurer provided medical information from a colorectal and general surgeon, referred to as Dr FM, that said the complainant had segmental colitis that likely was a flare-up of his diverticulitis, given his previous history with it.

AFCA noted that Dr ZN vehemently disputed the claims made by Dr FM, saying that his diagnosis was not acute diverticulitis and instead he treated the patient for gastroenteritis and colitis.

A report from the complainant’s gastroenterologist in Australia suggested that the traveller suffered acute diverticulitis whilst overseas, which was different from his pre-existing condition.

AFCA said Dr FM made a compelling and reasonable argument but was “essentially a desk top report made without having seen the complainant”. It said the overseas doctor had the benefit of seeing the patient when he was unwell and relied on his opinion.

The hearing acknowledged that if Dr ZN had access to the claimant’s medical history, he could have come to a different diagnosis.

AFCA noted the difficulty for the insurer to prove the illness had been from EMC because diverticulitis is predominantly confirmed by a colonoscopy, which Dr ZN had been unable to perform.

The decision said there was “little doubt” that the patient had an EMC of diverticulosis – which allows diverticula to form – but determined this condition was not the cause of the complainant’s “crippling pain”.

“I accept that the complainant has an underlying medical condition which could be considered an EMC and for which some of the symptoms may be similar and related,” AFCA said.

“However, despite the general likelihood of the statements by Dr FM, there is nothing that enables me to reject the opinion of Dr ZN as in any way unreliable.”

Zurich Australia was required to pay the claim if the complainant accepted the decision and any interest incurred from October 31 last year to the payment date if it was cash settled.

Click here for the full ruling.