SERVICE: Income Protection
OUTCOME: Settled
Issues: Policy Exclusion
Summary: Ms D’s complaint was settled, because the insurer agreed to accept the claim.
Ms D had income protection cover, with a mental health exclusion.
In October 2023, Ms D made a claim and said she was experiencing a return of concussion symptoms from an injury on 20 November 2020. She said she returned to work following the injury, but after working overtime and with the stress, the symptoms returned. Ms D said she was experiencing headaches, fatigue, difficulty concentrating and thinking, which made it impossible to work (the claim).
The insurer relied on the mental health exclusion to decline the claim. It said information from Ms D’s doctor indicated her symptoms were due to work pressure and burnout (rather than concussion) and, as such, the exclusion applied.
Ms D said the insurer had not properly considered the medical information. Ms D said she stopped work because of the daily headaches. She said her doctor initially believed this could be due to the concussion, but then the concussion clinic said it was not concussion related. Ms D’s Neurologist said it was possible that Ms D’s symptoms were from work pressures, but she also said the headaches were due to migraines.
The case manager’s assessment
The case manager discussed the complaint with the insurer and it said it wanted to obtain an independent report by a Psychiatry Professor. Following the receipt of this report, the insurer agreed to accept the claim in full and final settlement of the complaint.
*Name has been changed
Complaint No: 00232407