Urgent intervention gets results

What happened?

A complainant’s father was visiting him for an extended period from overseas and purchased private health insurance from an Australian provider for the visit.

Several months after arriving, the father became seriously ill and was twice admitted to hospital, where he was diagnosed with an aggressive form of cancer which needed urgent chemotherapy.

When he went to claim for his hospital admissions and treatment, the insurance provider denied his claim, saying the cancer was due to a pre-existing condition (PEC).

What did we do?

The complainant was distressed as his father could not get the critical treatment he needed, so he contacted our Office.

Understanding the urgency of the situation, our complaints team immediately escalated the complaint to try to get it resolved as quickly as possible. Staff from across the Office collaborated to help and share their expertise.

Further discussion with the complainant revealed that there was a potential issue with the insurer’s process for assessing the PEC – this was communicated to the insurer.

When we did not receive a timely response from the insurer, we contacted them again, reiterating our view that its process for assessing the PEC was potentially flawed.

Outcome of our investigation

The insurer wrote to the complainant the next day, telling him that his father was eligible to receive benefits under his policy. The complainant thanked us and said that he was greatly relieved, as his father could now receive the treatment he urgently needed, and he could also return to work as he had taken time off to care for him.