Dougal* made a claim for a specialist consultation and requested pre-approval for an adenotonsillectomy and grommet insertion for his daughter Sally*. After requesting Sally’s medical notes, the insurer found two references to Sally’s enlarged tonsils. They declined to cover the surgery, as they said they would have placed an exclusion on the policy if they’d known about the throat infection and enlarged tonsils. The pre-existing condition exclusion related to “any health condition, sign, symptom or event”, which existed before the policy commenced. The insurer placed an exclusion on the policy for adenotonsillar conditions, declined to pay for the consultation and the adenotonsillar surgery, but agreed to pay for the grommet insertion.
Dougal complained. After several discussions with the IFSO Scheme, the insurer agreed the exclusion should be for tonsils only. As a result, the insurer offered to pay for the initial consultation and for 50% of the adenotonsillectomy.
*Names have been changed.