Account of the case

A, born in 1986, requested a commitment to purchase a CPAP machine and the commencement of treatments and follow-up appointments payable by their employer’s health insurance.

The Insurance Company granted the payment commitment regarding the commencement and follow-up appointments. In its decision on the claim dated 20 September 2024, the Insurance Company refused to indemnify the expenses on acquisition of a CPAP machine since, according to the Terms and Conditions of the Policy, the assistive devices were not included in the expenses covered under Clause 4 of the Policy.

A sought redress of the Company’s negative decision on the claim through the Company’s internal appeal procedure. A pleaded the fact that the CPAP machine is indispensable for the treatment of sleep apnoea and the treatment had been prescribed by two doctors. A found that the list of compensable expenses in the Policy Terms, Clause 4, was only an example since under Clause 5 there is an exhaustive limitation of the listed expenses excluded from the scope of coverage of the Policy. The list of the exclusion did not expressly quote medicinal devices, such as the CPAP device. Therefore, A found that the CPAP device is compensable in line with the Policy Terms.

In its ruling of 17 October 2024, the internal appeal body of the Insurance Company found that the list of the compensable expenses under Clause 4 was exhaustive. In turn, Clause 5 lists expenses which are not covered even if such expense were to be included under Clause 4. Since medicinal devices were not listed under Clause 4, the CPAP machine was not compensable under the Terms and Conditions of the Policy. Moreover, the Insurance Company made reference to FINE’s recommended solution FINE-035398 which addressed the coverability of a CPAP machine.  The recommended solution in question found that the expenses incurred for the testing period and purchase of the CPAP machine were not compensable medical expenses as per Clause 2.2 of A’s medical expenses insurance Policy. For this reason, the Insurance Company was not obligated to compensate such expenses.

Customer’s claims

A is dissatisfied with the decision on the claim made by the Insurance Company. A claims that the expenses of the CPAP devices be compensated.

In the claim for rectification sent to the Insurance Company, A reiterates the standpoint already presented. A finds that the Policy Terms did not expressly mention the CPAP machine in the list of the coverable expenses but it was neither excluded from the list of expenses which were outside the scope of coverage. A finds that the list under Clause 5 of the Policy Terms has the purpose of ensuring that the Insured knows which expenses are not covered by the medical expenses insurance. On the other hand, the very existence of Clause 5 shows that the list of compensable expenses under Clause 4 is not exhaustive or sufficiently precise.

A also finds that the FINE Recommended Solution FINE-035398, referred to by the Insurance Company, is not fully relevant since in the case at hand, the Policy Terms had excluded medicinal devices from the scope of coverage. In A’s case, the medicinal devices have not been expressly excluded since they have not been listed in the exclusion. Should the Terms and Conditions intend to exclude such devices from the scope of coverage, this is misleading since A finds that the compensability of medicinal devices remains open to interpretation in light of the Terms.  

The opinion of the Service Provider

The Insurance Company repeats its earlier stand and finds that there is no reason to modify their decision on the claim.

The Insurance Company further finds that Clause 4 of the Terms list the expenses covered by the Policy. The list contained in the Clause is exhaustive. In addition, Clause 5 lists expenses which are not covered even if they would be compensable under Clause 4. The Insurance Company finds that Clause 4 does not allow for the conclusion that the CPAP or any other medicinal device would be covered by the Policy.

Contract Terms and Conditions

Under the Group Insurance Terms and Condition, in force as of 1 January 2020, Clause 4 (covered as medical expenses) provided that the examination or treatment is prescribed by a physician. Such medical expenses are

• charges of examination or treatment performed by a physician or any other healthcare professional
• charges for laboratory tests
• cost for medicinal products and would dressings available in pharmacies.
• daily hospital charges either in full or up to a certain maximum daily amount, as specified in the insurance Policy
• cost of examination and treatment of dental injury caused by an accident
• cost of dental care provided that such cares was necessary to heal a systemic illness
• costs of physiotherapy, foot therapy or occupational therapy necessary for recovery from a surgical operation or plaster treatment
  […]

According to Clause 5 (Limitations related to compensations), the insurance covers only the portion of medical expenses for which compensation has not been paid or for which the insured person is not entitled to compensation under the Health Insurance Act or some other legislation.

However, the insurance does not over medical expenses incurred due to

• examination or treatment which was not based on generally accepted medical practice and which was not necessary for the treatment of the illness or injury in question
• pregnancy, childbirth, abortion or infertility testing or fertility treatment
• acquiring an anthroposophical or homeopathic product or mineral, nutritive or vitamin preparation.
• […]

Recommended solution

The question at hand is whether the costs of acquiring a CPAP machine should be compensated from the health insurance. It is undisputed that the CPAP treatment has been prescribed a doctor. 

The voluntary health insurance will cover the medical treatment of the insured to the extent that has been agreed in the contract applicable to the Policy. In this Policy, the compensable medical expenses have been listed in the Policy Terms, Clause 4. This Clause contains a definition of the nature of medical expenses or acquisition that can be compensated on the basis of the Policy.

Under Clause 4, the medical expenses compensated are the charges of examination or treatment performed by a physician or any other healthcare professional, charges for laboratory tests, cost for medicinal products and would dressings sold in pharmacies, daily hospital charges either in full or up to a certain maximum daily amount, as specified in the insurance Policy, cost of examination and treatment of dental injury caused by an accident, cost of dental care provided that such cares was necessary to heal a systemic illness, costs of physiotherapy, foot therapy or occupational therapy necessary for recovery from a surgical operation or plaster treatment.

Moreover, the Policy can also be complemented with various Terms that limit the Insurance Company’s obligation to pay compensation. In this Policy, Clause 5 includes exclusions which limit the scope of compensation defined in Clause 4 of the Terms and Conditions. The medical expenses listed in Clause 5 will not be covered even if they were included in the list under Clause 4.

FINE points out that the premise of the interpretation of Policy Terms is – in line with the general principles of interpretation of contract law – the wording of the Terms and their significance that corresponds to the general use of the language. When interpreting the Policy Terms, they must be looked at as a whole.

A has pleaded the fact that the medicinal devices or the CPAP machine were not mentioned in the exclusions in Clause 5. A finds that the list of compensable expenses under Clause 4 of the Term is only an example while Clause 5 exhaustively lists the expenses that are not compensated based on the Policy. Moreover, A finds that the Recommended Solution FINE-035398 referred to by the Insurance Company is not applicable to their case since in that case, medicinal devices were expressly excluded from the scope of coverage of the Terms.

FINE finds that Policy Term 4 contains an exhaustive definition of the medical expenses covered by the Policy. By interpreting the Terms and Conditions based on the wording and as a hole, it is not justifiable to draw a conclusion that it would be a listing of an example nature. In turn, Clause 5 is a Term that limits the Insurance Company’s liability to compensate. Based on the Clause, it is not possible to draw a justifiable conclusion – looking at the Policy Terms as a whole – that the expenses of a CPAP machine would be compensable, irrespective of Clause 4, only because the CPAP machine or medicinal devices are not mentioned in the limitations concerning the payment of compensation. The condition for the compensability of treatment expenses is that they are costs defined under Clause 4, and therefore the Terms and Conditions cannot be seen as open to interpretation nor as unclear. FINE finds that the Insurance Company has no liability to pay compensation for the CPAP machine because it is not a question of an expense defined compensable under Clause 4.

As to the Recommended Solution FINE-035398 referred to by the Parties, FINE finds that in that case, it was also found that the compensability of the sleep apnoea treatment cost require that it is a question of medical expenses defined as compensable under Clause 2.2 of the Policy Terms. FINE found that the expenses incurred for the acquisition of the CPAP machine were not compensable since they were no such medical expenses as were defined compensable in the Policy Terms. Therefore, in that case, it was not necessary to apply the exclusion related to medicinal devices.

On the above grounds, FINE finds that the negative decision on the claim made by the Insurance Company corresponds to the Terms and Conditions.

Final outcome

FINE does not recommend that the Insurance Company's decision be modified.

FINE Advisory Office, the Finnish Financial Ombudsman Bureau

Head of Division Laine
Presenting Officer Pulkkinen