Dave’s melanoma claim
Article11 September 2023
It's not always black and white
Dave was diagnosed with a melanoma that technically didn't meet the policy definition of Cancer. But after a review of his claim he was still able to receive valuable financial support.
Dave's trauma cover and income protection claim
Dave took out insurance with OnePath in 2008, at the age of 37, to protect the financial future he wanted for himself and his family.
As a Civil Engineer and the primary income earner, Dave took out income protection covering himself for $9,135 per month, and a trauma cover policy for the total amount of $525,000. With protection in place, he enjoyed the peace of mind knowing that the financial future of his family would be secure if he was unable to work due to illness or injury.
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What happened...
10 years after taking out his trauma and income protection covers, Dave developed an unusual melanoma on his left eye.
In these instances, to claim on his policy, Dave would need to meet the policy definition of Cancer.
This definition is:
Cancer means the presence of one or more malignant tumours including leukaemia, lymphoma and Hodgkin’s disease characterised by uncontrollable growth and spread of malignant cells and the invasion and destruction of normal tissue. Melanomas are covered if they:
- Have evidence of ulceration; or
- Are at least Clark Level 3 depth of invasion; or
- Are at least 1.5mm Breslow thickness, as determined by histological examination.
As cold as these medical definitions may appear, we’re required to write medical definitions for our policies – not to find ways of getting out of claims – but rather, to be able to clearly identify those people who are impaired by their unfortunate circumstances, and whose claims are legitimate and need to be paid. The Clark Level and Breslow thickness are two measurements that are applied to determine the severity of a melanoma.
Because Dave’s melanoma developed on his eye, there was no way of performing a biopsy of the cancer to determine whether it met the medical definition. He required the full operation which would render him vision impaired regardless of whether the melanoma was of the thickness specified in his policy terms.
Our decision
Dave rightly claimed on both his income protection and his trauma cover.
Although it takes time to assess a claim properly, we began paying his monthly income protection benefits immediately to ensure he had some financial support during this difficult time.
At OnePath, there are people in our business who make human decisions on our claims, and while they use the policy definitions as a starting point, they have the intention of paying all legitimate claims that are aligned with the purpose of the product – to get people back to the financial circumstance they were in before the unfortunate event happened.
Dave’s case was a challenge to our policy definition. His case was severe – he was suffering a trauma which would potentially put him out of work – yet his case could not be determined to meet the terms of his insurance. But as the people on our claims team readily attested, Dave's suffering and impairment was in line with the reason we offer these products to customers, so his trauma benefit was paid in full.
At OnePath, we have the top-rated claims team in the country, and are proud to be there for our customers when they need us most.
Whilst the names have been changed to protect the individual claimant, this case study is based on the actual circumstances of the claimant. This is for illustrative purposes only, and claims will be assessed based on the specific circumstances of each individual case.
Zurich Australia Limited, trading as OnePath Life (ABN 92 000 010 195, AFSL 232510) (Zurich or OnePath) issues OneCare including OneCare External Master Trust and OneCare SMSF.
Brighter Super Trustee (ABN 94 085 088 484, AFSL 230511, RSE L0000178) (Trustee) is the trustee of Brighter Super (ABN 23 053 121 564, RSE R1000160) (Fund) and the issuer of OneCare Super. Zurich is the administrator and insurer for OneCare Super.
This information does not take into account your personal objectives, financial situation or needs. You should consider these factors and the appropriateness of the information to you. Consider seeking advice specific to your individual circumstances from an appropriate professional. You should also consider the relevant Product Disclosure Statement (PDS) for the product available at OneCare Policy Terms | OnePath or by calling us on 133 667 in deciding whether to acquire or continue to hold the product. Furthermore, some relevant products have been designed to meet certain objectives, financial situations and needs, which are described in its Target Market Determination available at Target Market Determinations | OnePath.
