Casper was hospitalised due to ischemic chest pain and submitted a hospitalisation claim for the expenses incurred. The insurer rejected the claim on the grounds that the condition was classified as a congenital anomaly and therefore excluded under the Policy.<\/p>\n\n\n\n
Exclusions<\/em><\/strong><\/p>\n\n\n\n The Company will not pay the Insured Benefits as stated in Clause 5.1 under this Policy, any of the following, whether directly or indirectly: \u2018Congenital Conditions\u2019 means any medical or physical abnormalities that existed at the time of birth or neonatal physical abnormalities developing within six (6) months from the time of birth. This will include all types of hernias and epilepsy except when caused by a trauma which occurred after the Effective Date.<\/em><\/p>\n\n\n\n PENEMUAN<\/strong><\/p>\n\n\n\n Casper\u2019s coronary angiogram revealed a diagnosis of \u2018myocardial bridge\u2019, a coronary anomaly. It occurs in about 5% of individuals and is a known cause of ischemic chest pain.<\/p>\n\n\n\n ICD\u201111 (Code BA60.0) classifies myocardial bridging under coronary artery anomalies, which are medically recognised as congenital in nature.<\/p>\n\n\n\n Although Casper\u2019s condition was diagnosed in adulthood, congenital anomalies can manifest symptoms later in life. The definition in the Policy relates to existence at birth, not the timing of diagnosis.<\/p>\n\n\n\n KEPUTUSAN<\/strong><\/p>\n\n\n\n The Ombudsman acknowledged the seriousness of Casper\u2019s condition but found that medical evidence confirmed \u2018myocardial bridge\u2019 to be a congenital coronary anomaly.<\/p>\n\n\n\n As the Policy expressly excludes congenital conditions regardless of when symptoms arise, the insurer\u2019s decision to reject the claim was consistent with the Policy terms. The adjudication was in favour of the insurer.<\/p>\n\n\n\n <\/p>","protected":false},"excerpt":{"rendered":" Casper was hospitalised due to ischemic chest pain and submitted a hospitalisation claim for the expenses incurred. The insurer rejected the claim on the grounds that the condition was classified as a congenital anomaly and therefore excluded under the Policy. Exclusions The Company will not pay the Insured Benefits as stated in Clause 5.1 under […]<\/p>","protected":false},"author":4,"featured_media":9974,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[25,27],"tags":[],"class_list":["post-9973","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-case-studies","category-insurance-takaful"],"acf":[],"yoast_head":"\n
Any treatment or surgical operation for Congenital Conditions<\/strong> or deformities, including hereditary conditions.<\/em><\/p>\n\n\n\n