No cover for knee replacement

Health insurance won’t pay claims for pre-existing conditions, unless the insurer has agreed to cover them.

Bad knee, no cover

In 2017, five years after taking out health insurance, Kate* made a claim for left knee replacement surgery as a result of osteoarthritis.

The insurer declined the claim, as the policy did not cover conditions which existed prior to the start of the policy (pre-existing conditions). This was because of a consultation Kate had with her doctor in July 2001, which stated “Probably the L knee has early degen[erative] changes from multiple minor trauma and wear and tear over many years”.

Kate said she had not experienced any further symptoms since the 2001 consultation. After speaking with the case manager about her medical history, Kate accepted that the condition of osteoarthritis in her left knee existed prior to the start of the policy in November 2002, and she knew this. Therefore, the insurer was entitled to rely on the exclusion to decline the claim.

Complaint not upheld.

See the full case study.