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.
