Exclusion clause Congenital
The Insured was diagnosed with Arteriovenous Malformation (AVM) and his hospitalisation claim was rejected on the ground that the admission was meant for diagnosis and treatment of congenital anomaly.
Investigation and Findings
The following findings were noted:-
- The Insured’s treating doctor did not conclusively affirm the Insured’s AVM is congenital.
- It was reported that the Insured’s recent haemorrhage at age of 65 was probably due to haemodynamic changes which could be due to the development of intracranial aneurysm which is acquired.
- No evidence was tendered by the Insurer to show that the Insured’s condition, i.e. ‘AVM’ is a congenital condition.
- The onus of proving that a claim is within the exception is on the Insurer.
- Recent evidence in medical literature also has highlighted the possibility of AVM to occur de novo, i.e. it was not congenital but due to other factors that provide the catalyst for the formation AVMs.
The Insurer revised their decision and paid the claim.