Utmost Good Faith: Insured and Insurer Binding Part IV. The insurer has a bigger role in Utmost Good Faith binding both parties, namely the insurer and the insured.

Liver Transplant Tragedy

Friday, June 7, 2002, on Singapore Strait Time, carried the title “Transplant tragedy:  Heartbreak for wife: ‘He died not knowing I was pregnant.’ Transplant tragedy: Too much money, Too little time, Frantic rush to raise funds. Liver Transplant Tragedy: “Donor available, but critical delay over cost proves fatal.”  No Money, No surgery.

A sorrowful heartbreak story flashed across the local daily newspaper. People cursed the heartless surgeon. The insurer refused to pay the so-called cash admission to the local private hospital. He was later transferred to another private hospital in Singapore for a liver transplant. The donor was none other than the late patient’s elder sister, who sacrificed her liver and spent countless sleepless nights to raise funds for her beloved younger brother.

Jaundice

The local hospital diagnosed him as suffering from jaundice. He needed to pay the admission fee of RM5,230.00. The medical card was supposed to be a cashless admission. Finally, the consultant confirmed he was suffering from hepatitis B. Like adding salt to the wound, time delay, and the patient in critical condition, the ambulance rushed him off to a Singapore private hospital to perform the liver transplant.

No money, no surgery

“First you need to find the right donor for a liver transplant; secondly, S$300,000 in full payment as a cash deposit before the surgeon can operate.” The hospital concerned informed them, “No money, no surgery.”

To cut the story short, the money was raised, and the elder sister was admitted to the hospital for a liver transplant on the following day. Her youngest brother, who could not hold longer, was called to be with the Lord in the wee hours of the morning.

Whatever is gone, ash to ash, dust to dust, but the living need to go on with their lives. The deceased family filed a claim for a sum insured of RM75,000.00 to the general insurance company for the medical card claim. It was a shocking reply from the insurer.

Not Claimable

It is with deep regret that I inform you that the medical expenses for the treatment of your condition are not claimable under the following policy exclusion:

General Exclusion (11): “suicide or attempted suicide, self-inflicted injuries, self-destruction or any attempt thereat while sane or insane. ”

General Exclusion (9): “… treatment of alcohol dependence syndrome and drug addiction/abuse.”

After countless visits to the hired lawyer, there is no outcome. But the lawyer charged the family RM2,000 to open a file. Also, numerous appeal letters to the Malaysia Mediation Bureau turned out fruitless.

It was a coincidence I stumbled across his sister, and after a few chats, we realised we were colleagues before. We chatted over a high tea.

” Jamin Wong, can you please help me to claim my late brother’s case? Since after we departed, you continued with your Chartered Insurance study, I am sure, and you have the confidence to help me.” She pleads with me.

” Sure, It is my pleasure to help with those genuine claims, but this lawyer’s correspondence letter, please do not give it to me. I want the proposal form, cover note, policy jacket, and rejection claim letter. If I had 90% winning the case, I would write an appeal letter on your behalf to Bank Negara Insurance Mediation Bureau. Is that OK with you.

In the proposal form, the brother wrote that he was a hepatitis B carrier. Also, there were no exclusion clauses specified in a few years’ renewal. A close study of the liver specialist’s diagnostic report confirmed the patient died of acute liver failure due to hepatitis B.

The insurer did not honour Utmost Good Faith

The insured had carried the duty of Utmost Good faith in disclosing he was a hepatitis B carrier in the proposal form. Whereas the insurer did not honour the Utmost Good faith on their part.

Happy Ending

With just one A4 paper size written in the appeal letter. All happy endings. On 30-7-2004, the widow received a cheque amounting to RM75,000 from the insurer.

Two policies cover the same consignment, a small claim response, but a bigger, sun-insured claim was rejected. Another story does not follow the Utmost good Faith rule by the insurer; more in the next episode.

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