Tami complained to us because her insurer declined her personal accident claim.
What happened
Tami experienced gradual pain in her knee while hiking which went on to badly damage her knee.
Her insurer said the claim wasn’t covered because it didn’t think her injury was caused by something external to the body – which was required under the policy definition.
Tami didn’t think her insurer had processed her claim correctly, and if it did – it would’ve accepted her claim. She raised a complaint. Unhappy with how the insurer handled her claim and its final response, she referred her complaint to us.
What we said
We started reviewing the policy terms. Tami’s policy said a customer must suffer death or bodily injury as a direct result of an unexpected, external, violent and visible cause.
We then reviewed the medical evidence and Tami’s testimony. The evidence showed she suffered gradual wearing of the protective cartilage in her knee joint. The length and difficulty of the hike exacerbated the condition and eventually caused bone damage. Tami said she felt her pain become worse but chose to complete the hike.
We asked Tami if she fell over or tripped or struck her knee against anything during her hike. Tami said she hadn’t, but she thought that was irrelevant. We said it was relevant whether something specific had caused her injury, because the policy said the accident must be caused by an event that’s external to the body. We didn’t think that feeling a gradual or sudden pain inside the knee was an event that was external to the body.
We told Tami we didn’t think the insurer had acted unreasonably – so we didn’t think the insurer should pay her claim.