It's not always black and white
Dave was diagnosed with a melanoma that technically didn't meet the policy definition of Cancer. But after a review of his claim he was still able to receive valuable financial support.
Dave's trauma cover and income protection claim
Dave took out insurance with OnePath Life in 2008, at the age of 37, to protect the financial future he wanted for himself and his family.
As a Civil Engineer and the primary income earner, Dave took out income protection covering himself for $9,135 per month, and a trauma cover policy for the total amount of $525,000. With protection in place, he enjoyed the peace of mind knowing that the financial future of his family would be secure if he was unable to work due to illness or injury.
10 years after taking out his trauma and income protection covers, Dave developed an unusual melanoma on his left eye.
In these instances, to claim on his policy, Dave would need to meet the policy definition of Cancer.
This definition is:
Cancer means the presence of one or more malignant tumours including leukaemia, lymphoma and Hodgkin’s disease characterised by uncontrollable growth and spread of malignant cells and the invasion and destruction of normal tissue. Melanomas are covered if they:
- Have evidence of ulceration; or
- Are at least Clark Level 3 depth of invasion; or
- Are at least 1.5mm Breslow thickness, as determined by histological examination.
As cold as these medical definitions may appear, we’re required to write medical definitions for our policies – not to find ways of getting out of claims – but rather, to be able to clearly identify those people who are impaired by their unfortunate circumstances, and whose claims are legitimate and need to be paid. The Clark Level and Breslow thickness are two measurements that are applied to determine the severity of a melanoma.
Because Dave’s melanoma developed on his eye, there was no way of performing a biopsy of the cancer to determine whether it met the medical definition. He required the full operation which would render him vision impaired regardless of whether the melanoma was of the thickness specified in his policy terms.
Dave rightly claimed on both his income protection and his trauma cover.
Although it takes time to assess a claim properly, we began paying his monthly income protection benefits immediately to ensure he had some financial support during this difficult time.
At OnePath Life, there are people in our business who make human decisions on our claims, and while they use the policy definitions as a starting point, they have the intention of paying all legitimate claims that are aligned with the purpose of the product – to get people back to the financial circumstance they were in before the unfortunate event happened.
Dave’s case was a challenge to our policy definition. His case was severe – he was suffering a trauma which would potentially put him out of work – yet his case could not be determined to meet the terms of his insurance. But as the people on our claims team readily attested, Dave's suffering and impairment was in line with the reason we offer these products to customers, so his trauma benefit was paid in full.
At OnePath Life, we have the top-rated claims team in the country, and are proud to be there for our customers when they need us most.
Whilst the names have been changed to protect the individual claimant, this case study is based on the actual circumstances of the claimant. This is for illustrative purposes only, and claims will be assessed based on the specific circumstances of each individual case.
OneCare is issued by OnePath Life Limited (OnePath Life) ABN 33 009657 176, AFSL 238341. OneCare Super is issued by OnePath Custodians Pty Limited (OnePath Custodians) ABN 12 008 508 496, AFSL 238346. OnePath Life is not a related body corporate of OnePath Custodians. We recommend that you read the OneCare Product Disclosure Statement and Policy Terms available at www.onepath.com.au or by calling 133 667 before deciding whether to acquire, or to continue to hold the product.