Terms and Conditions: Ambiguity in the Policy

Background

Mr Athi (not his real name) met with an accident while riding a motorcycle and was hospitalised for treatment of his multiple bones’ fractures. He made a claim against his insurer for the medical costs. Unfortunately, his claim was declined on the grounds that Mr Athi’s hospitalisation was due to a disease or disorder of the bones and tendon which fell under the policy endorsement to exclude benefits under this condition.

 

Investigation and Findings

The Case Manager reviewed Mr Athi’s dispute and noted the following policy endorsement.

“In addition to the terms, conditions and exclusions of this Policy, no benefit will be payable for any disease or disorder of nervous system, bones, tendons/joint and supporting tendinous & ligamentous structures of right lower limbs or any complication thereof from the policy.”

 

The Case Manager pointed out to the Insurer that medical condition caused by a disease or disorder differs from medical condition caused by injury due to accident. Disease is defined as ‘a disorder of structure or function in human, especially one that produces specific symptoms that affects a specific location and is not simply a direct result of physical injury’. In the present case, Mr Athi’s medical condition is a direct result of physical injury. The policy endorsement did not include physical injury.

The Case Manager opined that the omission of the word ‘injury’ in the endorsement creates ambiguity and this has led Mr Athi to believe that he would be able to seek coverage under the policy as his condition was not due to a disease or disorder.

 

Settlement

The Insurer considered the Case Manager’s findings and settled the claim accordingly.