Raju was admitted to Institut Kanser Negara due to ‘Superobese with Metabolic Syndrome, Mechanical Issues and Cholelithiasis’. He made a claim under Daily Hospital Income and Surgical Benefits.

The insurer repudiated the claim because the hospitalisation falls under the policy provision of the 30-day waiting period, Specified Illness, and treatment for weight loss.

OUR FINDINGS

According to the medical report, Raju visited the Bariatric Clinic for the diagnosis of ‘Superobesity with metabolic syndrome and mechanical issues’, which were initially diagnosed during the 30-day waiting period. During his hospitalisation, an ultrasound of the hepatobiliary system revealed Raju’s Cholelithiasis condition or gallstones.

We note that Raju’s condition of ‘Superobese with metabolic syndrome and mechanical issues’ was first diagnosed during the 30-day waiting period. However, his gallstone condition was discovered later, after the 30-day waiting period and the 120-day specified illness clause. Moreover, the treating doctor did not indicate that the cholelithiasis is related to Raju’s superobese condition; instead, it was discovered incidentally during the investigations.

OUTCOME

Considering all factors, we recommended the insurer consider paying the claim to Raju on a prorated basis for the Cholelithiasis condition, which they agreed to, and the matter was settled amicably.