HOW INSURANCE COMPANIES TRIED TO AVOID PAYING UP


CASE 2

An elderly person had an insurance policy to cover 36 critical illnesses. He suffered a stroke (an illness covered by his policy) and lost mobility in one arm; thus, he put in a claim. However, the claim was denied by the company, resulting in him making a complaint to CAP.

CAP wrote to the company asking for the reason(s) for declining the claim. The reply was shocking to say the least. It stated that the stroke was caused by the rupture of some blood vessels in the brain, and as all blood vessels are connected to the heart, the stroke was actually a heart problem which was not listed in the 36 critical illnesses. As such, the company was not liable to pay.

CAP countered the company’s novel argument by pointing out that heart problems are CARDIOVASCULAR and brain problems are CEREBROVASCULAR. Furthermore, a heart surgeon does not operate on the brain and a brain surgeon does not operate on the heart.

Accompanying this reply was a letter that had been obtained from the complainant’s surgeon who refuted the company’s doctor’s story that strokes were heart problems.

The company did not reply CAP’s letter but paid up the claim of RM50,000.

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