These case studies have been modified so as not to identify any actual cases at FIDReC. They are provided for purposes of learning and are not necessarily indicative of outcomes at FIDReC.
One day, while bending down to retrieve an item that had fallen on the floor, Frank felt a sharp pain in his back that caused him to fall to the floor. Afterwards, Frank continued to suffer from weakness in his legs and a sharp back pain. This significantly affected his movement and walking. He consulted a doctor who referred him to an orthopaedic surgeon. The orthopaedic surgeon ordered an MRI scan, which revealed that the cause of his discomfort was a disc herniation.
Frank filed a claim with his insurer under his personal accident policy that had a medical reimbursement coverage of S$2,000. However, the insurer rejected his claim because the circumstances did not fall within the scope of policy coverage. The insurer explained that for the claim to be eligible, under the policy wordings, the accident must be caused by a “sudden, external force”. The insurer also highlighted that the policy also excluded accidents that result from a medical condition.
Frank disagreed with the insurer’s assessment of the claim and reasoned that an accident had occurred when he bent over to pick up the item. From his understanding as a layperson, a personal accident policy should cover him in such instances where he suffered from a fall.
Frank filed a claim at FIDReC that proceeded to mediation. During mediation, both parties kept to their respective positions. As there was no resolution, Frank opted to receive a Mediator’s Indication where an experienced Neutral shared his view on the matter. At the session, the Neutral expressed his views that the policy wordings were clear and unambiguous. The Neutral found it unlikely that Frank would succeed in his claim against the insurer.
Despite receiving the indication, Frank decided to proceed for adjudication. After the hearing and reviewing the evidence, the Adjudicator found that the policy wordings clearly required there to be a “sudden, external force”. This was not present on the facts. Further, the Adjudicator found that the findings of slipped disc during the MRI was evidence that there was an underlying medical condition involved. As a result, the claim would fall under the scope of the exclusion clause. The claim was therefore dismissed.
Key Learning Points
Consumers should read the terms and conditions of personal accident policies before purchasing. Not all personal accident plans have the same coverage. Some policies might exclude activities, such as participating in sports or accidents occurring in the gym.
Consumers should take note that personal accident policies require that an accident occurs before policy benefits are payable. Each policy will contain specific definitions of an “accident”, and this may differ from insurer to insurer.
Most policies will contain an exclusion if the accident arises from a medical condition.
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