Mr Lim was diagnosed with advanced Oesophageal Cancer that had spread to his right face and right arm muscles. His doctor recommended chemotherapy combined with immunotherapy treatment to prevent the cancer from getting worse.

The insurer honoured his medical expenses but excluded charges for Immunotherapy Treatment based on the following policy provision:

‘16. Annual OutPatient Cancer Treatment (Reimbursement only) ‘If an Insured Person is diagnosed with Cancer as defined below, the Company will reimburse the Reasonable and Customary Charges incurred for the Medically Necessary treatment of cancer performed at a legally registered cancer treatment centre subject to the limit of this disability as specified in the Schedule of Benefits. Such treatment (radiotherapy or chemotherapy excluding consultation, examination tests, take home drugs) must be received at the out-patient department of a Hospital or a registered cancer treatment centre immediately following discharge from Hospital confinement or surgery.’

OUR FINDINGS

Mr Lim’s attending doctor has confirmed that immunotherapy in combination with chemotherapy is a vital treatment regime and medically necessary. The word ‘such’ in the provision means it is not limited to radiotherapy and chemotherapy only.

The policy should clearly state whether the insurer intended to exclude immunotherapy treatment. According to the Contra proferentem Rule, any ambiguity in the policy must be interpreted in favour of the insured.

Certain insurance companies cover immunotherapy treatment despite using similar language in their policy provisions. Immunotherapy is FDA-approved and registered with the Ministry of Health of Malaysia. It uses the patient’s immune system to fight cancer by activating or suppressing it.

Mr Lim, who is a layperson and diagnosed with a terminal illness, should not be penalised for adhering to the treatment advised by his doctor.

OUTCOME

Based on the above reasons, the Ombudsman decided that it is fair and reasonable for the insurer to cover the cost of immunotherapy as part of Mr Lim’s cancer treatment.