CR183 Exclusion clause – HIV diagnosed after application date but prior to the commencement date.
Exclusion clause – HIV diagnosed after application date but prior to the commencement date.
The life insured applied for a policy on 4 May 2004. On 14 June 2004 the life insured was diagnosed as being HIV positive. The commencement date of the policy was 1 July 2004. On 29 November 2004 he died as a result of pulmonary embolism. The insurer declined the claim as the HIV diagnosis:
“is before the inception date. It is a pre-existing medical condition and is therefore excluded in terms of the policy provisions.”
The policy provided as follows:
”In the event of there being any claim under this benefit within 24 (twenty four) months from the commencement date or most recent date of reinstatement or any increase in cover (other than inflation growth), following the life assured’s death which is in [the insurer’s] opinion, based on medical evidence supplied by the life assured’s medical practitioner at the time of his death, due to or arising from a medical condition of any nature whatsoever from which the life assured was suffering at the time of his application for this benefit, no payment shall become due under this benefit, which shall be void and all premiums paid in respect thereof shall be forfeited.”
We took the view that “the time of his application for this benefit” was 4 May 2004 (the date of proposal). According to the medical information submitted in support of the claim, the blood test was done on 14 June 2004. This was after the time of “his application for this benefit”. We suggested to the insurer that the claim be paid, as the life assured’s medical practitioner did not provide any medical evidence indicating that the life assured was suffering from a medical condition that contributed to his death at the date of application for the benefit.
The claim was settled.