Exclusion Clause: Pre-Existing illness
The claim was filed by the complainant for death benefit of her deceased husband (participant). She contended that she should be entitled to claim the death benefit as her deceased’s husband did not suffer from for any illness, i.e. ‘hypertension’ prior to the inception of the Certificate.
Investigation and Findings
The complainant’s claim was repudiated by the takaful operator on the ground that the participant had pre-existing illness prior to the commencement of the Certificate’s coverage.
The takaful operator’s decision was based on the medical note prepared by Klinik ABC dated 1 February 2016 and the exclusion of the Certificate which states as follows:
“Part 5. Exclusions
Pre-existing condition shall mean any injury or illness:
which existed or have developed symptoms prior to effective date of coverage; or
where a manifestation of an illness is in existence prior to effective date of coverage of which the covered member was aware of or should reasonably has been aware; or
based on medically accepted pathological development of the illness; such illness would have existed prior to coverage effective date.
1.2. No benefit is payable if pre-existing condition is the material cause of death...”
The Case Manager observed that the attending doctor had stated ‘BP 140/90’ on several occasions in the medical note. However, there was no indication by the attending doctor that the participant was suffering from ‘‘hypertension’ or precribed with related medications.
In this regard, the Case Manager opined that the high blood pressure reading on few occasions could not be taken as conclusive medical evidence to indicate that the participant was suffering from a particular illness, i.e. ‘hypertension’.
The Case Manager highlighted to the takaful operator that there must be clear medical evidence that the participant was diagnosed with hypertension before completing the application/proposal form and the statement must be supported by factual evidence, in particular the date of diagnosis, the name of the doctor who made the diagnosis and the treatment/medication prescribed.
The takaful operator requested for further medical information, that is, the participant‘s previous medical report. However, there was no documentary evidence provided to indicate that the participant had hypertension prior to the commencement date.
The takaful operator revised its decision and settled the complainant’s death benefit claim.