Helen sought treatment for a small lesion on her left groin that had been present for approximately two years. She successfully underwent outpatient removal of the lesion at SJ Hospital.

The insurer, however, rejected her claim, citing the policy exclusion for plastic and cosmetic procedures, which includes the removal of benign lesions.

Exclusions

The Company will not pay the Insured Benefits as stated in Clauses 4.3.1 to 4.3.18 under this Annexure as a result of, including of any of the following whether directly or indirectly:

Plastic/cosmetic Surgery, circumcision, eye examination, glasses, and refraction or surgical correction of nearsightedness (Radial Keratotomy or Lasik) and the use or acquisition of external prosthetic appliances or devices such as artificial limbs, hearing aids, implanted pacemakers and prescriptions thereof;

PENEMUAN

Histopathological examination confirmed that the lesion was a benign seborrheic wart, measuring only 5mm, with no evidence of malignancy, pain, bleeding, itching, or functional impairment. The removal had been performed as a precautionary measure due to concerns about potential malignancy.

Under the policy, coverage is limited to treatment that is deemed medically necessary for a covered illness or disability. Given the lesion’s benign and asymptomatic nature, the procedure was classified as cosmetic rather than medically necessary.

The insurer’s reliance on the exclusion clause for cosmetic and plastic procedures is consistent with the policy wording and the contract terms.

KEPUTUSAN

Upon review, it was determined by the case manager that the insurer’s reliance on the exclusion clause for cosmetic and plastic procedures is consistent with the policy wording and the contract terms. Helen did not respond to the case manager’s recommendation, and the case was closed.