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CR326 Interpretation / Exclusion

CR326

Interpretation / Exclusion

Interpretation – meaning to be given to wording of an exclusion for “intervertebral disc disorders” – insurer using International Classification of Diseases (ICD) coding and descriptions

Background

1. The complainant was hospitalised for a back operation and, having been off work for some months, claimed sickness benefits under his policy. His claim was rejected, the insurer maintaining that his sickness fell within the ambit of an exclusion on his policy for “intervertebral disc disorder”. This exclusion had been imposed at application stage after the complainant disclosed two prior incidents, one a spinal stenosis necessitating a back operation many years earlier, and the other a slipped disc.

2. The insurer stated that in interpreting the exclusion for intervertebral disc disorder, it made use of the ICD 10 Code M51, and that in so doing the exclusion “was meant as a broad exclusion, covering the entire spine”. According to the insurer the ICD 10 M51 description included thoracic, thoracolumbar and lumbosacral disc disorders. The complainant’s latest back operation had been for spinal stenosis, at a higher level on the spine than previously. The insurer argued that the exclusion applied because a “spinal stenosis is generally regarded as an intervertebral disc disorder”.

3. We asked the insurer to explain what “ICD 10 Code M51” stood for, and what it provided for. We also asked the complainant to obtain a written opinion from his surgeon on whether or not the spinal stenosis could be considered in his particular case to be an intervertebral disc disorder.

4. The insurer replied that ICD stood for the International Statistical Classification of Diseases and Health Related Problems, a coding system endorsed by the World Health Organisation (WHO), and that 10 refers to the 10th Revision of the code, which is the international standard diagnostic classification for all general epidemiological purposes, for many health management purposes, and for clinical use. They added that some insurers use the coding system to describe diseases and other health problems for the purpose of defining policy exclusions, and referred us to the WHO website which sets out the various codes and descriptions.

5. In a letter the complainant’s surgeon elaborated on the diagnosis of spinal stenosis, explaining that the complainant “was operated for an intradural arachnoid cyst which caused compression of his cauda equina. It is seen as a benign cyst”.

Discussion

6. We reviewed the ICD codes on the WHO website, and noted that spinal stenosis was not in fact classified under M51, being “Other intervertebral disc disorders”, but under M48 as “Other spondylopathies”. As the diagnosis of the complainant’s condition was spinal stenosis, we put it to the insurer that this did not appear to fall within the terms of the exclusion on the policy, as it was not an intervertebral disc disorder.

Result

7. After considering the additional medical information, the insurer accepted that there was insufficient evidence of the presence of an intervertebral disc pathology, and agreed to pay the claim.

SM
January 2012

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