Haku

FINE-018924

Tulosta

Asianumero: FINE-018924 (2019)

Vakuutuslaji: Matkavakuutus

Ratkaisu annettu: 14.08.2019

Lakipykälät: 69

Travel-related illness. Malaria and typhoid fever. Was it proved that a travel-related illness, as defined in the policy terms, had occurred?

Information about the event 

On 12 November 2018, the customer informed the insurance company by phone that he had fallen ill during his trip. The customer stated that he left Finland on 23 October 2018 and returned to Finland on 8 November 2018. According to the customer, he was hospitalised in Nigeria for 11 days, starting on 26 October 2018, for malaria and vomiting. The customer informed the insurance company that he paid 635,000 Nigerian nairas for his treatment. 

On 30 January 2019, the insurance company made a negative decision in the matter. The insurance company stated that according to the reports submitted by the customer, he developed malaria symptoms three days after his arrival in Nigeria. The customer tested positive for P. falciparum malaria on 27 October 2018. The insurance company referred to general medical knowledge, according to which the incubation period for P. falciparum malaria is at least one week and the disease is not found in Finland. The insurance company thus judged it impossible that the customer could have contracted the infection during the trip in question and considered that, based on this information, the nature of the customer’s illness remained unclear. The insurance company found the customer’s claim for compensation too high and considered that no proof had been presented for the payment of the fee. 

The customer submitted to the insurance company a letter dated 2 February 2019, in which he stated that in Nigeria, it is possible for malaria symptoms to appear even after an incubation period of just one day. The circumstances are different from Finland. The customer also provided further details on the costs. 

The insurance company did not change its earlier decision. In a decision dated 2 March 2019, the insurance company indicated that it had been in contact with the clinic and received information according to which the customer had been treated mainly for typhoid fever. According to a statement dated 5 November 2018, the customer had tested positive for salmonella (Typhoid enteritis). 

The insurance company observed that typhoid fever, too, usually has an incubation period of 1 to 2 weeks, rarely shorter than that. In the insurance company’s view it was equally unlikely that the customer could have contracted typhoid fever during his trip. In addition, the information received from the clinic concerning the sum paid differed from the information given by the customer.

Customer claims at FINE and the opinion of the Service Provider

The customer states that the insurance company gave differing motivations in its decisions and based them on assumptions. The insurance company processed the case in an unfair manner and with discrepancies. The customer demands 635,000 nairas, or approximately EUR 1,555, as compensation. 

The insurance company refers to the compensation decisions made in the case.

Policy Terms and Legislation 

Fixed-term travel insurance (insurance terms effective from 1 January 2017, unofficial translation by FINE) 

4.2 Travel-related illness
Travel-related illness is a sudden and unexpected illness requiring medical attention, the first symptoms of which appeared during a trip while the insurance cover was valid and which, according to general medical experience, must be judged to have originated during the trip. If any symptoms of the illness appeared before the trip started or if tests or treatments were ongoing before the customer left for the trip, the illness is not considered a travel-related illness even if it is diagnosed during the trip. […]

Insurance Contracts Act (543/1994) 

Section 69. Claimant's duty of disclosure.
The claimant shall provide the insurer with such documentation and information as is required for assessing the insurer's liability and as the claimant can be reasonably required to provide, with due consideration of the opportunities available to the insurer to obtain such information.

Decision

The question raised in this case is whether the customer has been able to provide sufficient proof and reports of having contracted a travel-related illness, as defined in the insurance terms, during his trip. 

As the law now stands, the compensation claimant has the burden of proving that a loss that is compensable under the terms of the insurance policy has occurred.

Under the insurance terms, costs are compensated for illnesses whose first symptoms appeared during the trip and which, according to general medical experience, must be judged to have originated during the trip. 

According to the reports submitted by the customer to the insurance company, he was hospitalised with malaria and typhoid fever from 26 October until 5 November 2018 during his trip to Nigeria, which took place from 23 October until 8 November. The documents provided by the customer included a receipt issued by the clinic with a breakdown of the fees, a laboratory test result report, a doctor’s statement and bank statements. The doctor’s statement indicates that when the customer came for treatment, he was suffering from stomach pain, fever, diarrhea, vomiting and cough. Laboratory tests showed the presence of the malaria parasite Plasmodium falciparum and of salmonella. The customer was put on an IV drip and he was also administered antibiotics intravenously. According to the notes, he was also treated for malaria. His symptoms gradually disappeared and he was discharged on 5 November 2018. The insurance company refused compensation for treatment costs on the ground of the incubation periods of the diseases and the insufficiency of the reports. 

According to the Duodecim Terveyskirjasto health library, falciparum malaria is a tropical disease requiring a climate where the average daily temperature stays at 28 °C or higher for at least three consecutive weeks at a time. The time from the infectious mosquito bite to the first symptoms of falciparum malaria is at least 7 days, often 2 to 4 weeks. (https://www.terveyskirjasto.fi/terveyskirjasto/tk.koti?p_artikkeli=dlk00620, retrieved on 31 July 2019)

According to the public health operational guidelines of the Finnish National Institute for Health and Welfare, typhoid fever caused by the Salmonella Typhi bacteria usually has an incubation period of 7 to 14 days, although ranging from 3 days at the shortest to 60 days at the longest. (Public health operational guidelines for Salmonella Typhi (typhoid fever) and Salmonella Paratyphi (paratyphoid fever) cases [in Finnish], 1 July 2019, https://thl.fi/fi/web/infektiotaudit/taudit-ja-mikrobit/bakteeritaudit/salmonella/toimenpideohje-salmonella-typhi-lavantauti-ja-salmonella-paratyphi-pikkulavantauti-tapauksiin, retrieved on 31 July 2019)

FINE notes that both diseases typically have a longer incubation period than the three days between arrival in the country and falling ill that were reported in this case. FINE finds that it has not been demonstrated in this case that the customer contracted an illness that originated during the trip, as defined in the insurance terms. FINE thus has no grounds for recommending that the insurance company should compensate the costs. 

Final outcome

FINE does not recommend a change in the case.

FINE
The Finnish Financial Ombudsman Bureau FINE

Head of Division Hanén                 
Presenting official Salo
 

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