Cancer patient’s claim denied despite medical support: RC

The Royal Commission has today heard that a CommInsure customer was denied a claim following breast cancer surgery as she did not have to undergo a full mastectomy, despite two doctors confirming to the insurer that her procedure was “radical breast cancer surgery”.

CommInsure’s definition of what “radical” surgery was that was needed to make a successful claim was not specified, but its managing director, Helen Troup, acknowledged it relied on a definition of cancer that was 18 years old and had limitations imposed on it which were not referred to in any of its policy documents.

These limitations were also imposed in a way which didn’t account for the way the customer had been treated by her doctors or the medical opinions expressed by those doctors. This revelation came just hours after the Commission heard evidence that CommInsure’s definition of a heart attack was outdated.

After the customer’s original claim was denied for not being “radical”, she got evidence from both the surgeon who operated on her and her GP that, in their medical opinion, the procedure she underwent was “radical”.

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CommInsure’s medical consultant again denied the claim in light of the new supporting documentation and, when it was escalated to the firm’s operational claims committee, where claims could be discussed amongst various members of the complaints team, the denial was upheld.

The letter confirming the denial received by the customer on 15 March 2017 said: “We appreciate that radical surgery is not defined in the relevant product disclosure, however radical surgery pertaining to the breast means radical mastectomy, which refers to the removal of the entire affected breast.”

When asked whether the reliance on an older definition or the above limitations was acceptable by Senior Counsel assisting the Commission, Rowena Orr QC, Troup admitted that this was not.

“I think that there were two errors that CommInsure’s processes and procedures should have addressed and they didn’t,” Troup said.

She said that firstly, the difference in medical opinion between the claimant’s doctors and CommInsure’s medical team should have been reviewed and resolved, and the review should have then been escalated to a higher level.

“I think if those two things had happened [the claim] would have resulted in a different outcome,” Troup said.

CommInsure did not update its definition around breast cancer until May, last year.