Karina’s endometriosis claim
Article11 September 2023
There's a human side to claims
Karina's claim technically didn't meet the definition of endometriosis in her policy. But that didn't stop her claim from being paid in full.
Karina's trauma cover claim
In 2008, at the age of 36, Karina took out Trauma Premier Cover with OnePath for the total amount of $63,000. She felt more confident knowing that her debts would be covered should something happen to her.
A satisfied customer of almost 10 years, in November 2017, Karina was diagnosed with endometriosis – a painful tissue condition of the uterus that often requires surgical intervention.
What happened...
Endometriosis means the presence of endometrial tissue (normal lining of the uterus) outside the uterus, usually in the pelvic cavity.
In OneCare's policy definition, 'Endometriosis (severe requiring surgical intervention)' requires the surgical mobilisation of the rectum, excision of deposits from the rectum and other parts of the pelvis, and freeing of adhesions. Mild and moderate endometriosis and adenomyosis are excluded.
The requirement of surgery as a treatment is used to identify people diagnosed with endometriosis who will be significantly impacted by their disease, as they will need most support. Karina's claims consultant, Fred, noticed that Karina’s doctor had not advised surgery as a treatment for Karina – yet she was clearly suffering significant impairment from her condition. Fred investigated further.
Unfortunately for Karina, her endometriosis had become so severe that surgical intervention would be disabling for her due to the sheer size of the infected tissue. Her doctor advised against surgery, which would be extensive and life threatening, meaning that her particular circumstances did not strictly meet the policy definition.
Our decision
Fred did not hesitate in identifying Karina’s case as one which, while outside the strict policy definition, was aligned with the intention of supporting customers who suffer a severe trauma. He brought this case to the in-house Claims Review Forum with the recommendation that this claim be paid in full.
Trauma cover is there to help people like Karina survive the financial consequences of a health crisis, and that’s exactly what happened.
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.
