Bank wrong to reject insurance claim over visit to hip specialist

Health insurance,
Harry made a claim on his insurance policy for a disability caused by an infection in his left hip joint, which was discovered after he went to an emergency department in January 2019 with acute hip pain.
April 2022

The bank declined the claim on the grounds he had gone to a specialist about hip-related problems in January 2018, just one month before applying for the policy. It said it was declining the claim in accordance with a clause in his policy that said he was not covered for "any medical condition for which medical advice, consultation or treatment was required in the six months immediately preceding start date of this policy”. He was not satisfied with this response and asked us to investigate.

Our investigation

There was no question Harry sought medical advice from a specialist about his left hip in the month before the policy’s start date. However, the exclusion wording appeared to be limited to any “medical condition” that existed in the six months before the start date of the policy – not a disability caused by or related to that medical condition. The medical condition causing his disability was an infection in the left hip. Medical notes from his specialist showed he had no infection at the time of the visit, but rather intermittent pain probably caused by a tendon in the hip. It appeared likely that the infection could have been caused by a procedure on his hip in September 2018 – after the policy had started. We put this to the bank and asked it to set out why it believed the exclusion applied. 


The bank’s response was to agree to pay the claim.

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