Account of the case

A was insured under a group health insurance policy between 1 August 2014 and 31 July 2015. He has claimed compensation for treatment expenses incurred starting from 12 August 2015. The Insurance Company has denied compensation. According to the decision of the Company, the insurance policy must be in force when the expenses are incurred.

Customer’s complaint

A claims compensation for the treatment expenses. This is an insurance event that occurred during the Insurance Company’s liability period. A refers to Subclause 202.1.1. of the policy terms. According to the clause, the insurance will cover treatment expenses in a situation where the insurance event has occurred or symptoms of the illness have appeared during the period of validity of the policy.

Reply by the Insurance Company

The Insurance Company contests the claim made by A. According to the Company, the policy terms are clear both in Finnish and in English. Treatment expenses are compensable on two conditions. The insurance cover must be in force when expenses are incurred and, secondly, the insurance event or illness or respective symptoms must have started during the period of validity of the insurance policy. In the case at hand, the expenses have been incurred after the expiry of the cover.

Medical reports

The Insurance Complaints Board has had access to the following medical data: patient record notes of 30 June 2015, 20 July 2015, 27 July 2015, 31 July 2015, 14 August 2015, 18 February 2016 and 19 February 2016. Moreover, the Board could avail of the referral of 30 July 2015. The medical reports show that A's need for treatment is related to cancer

Recommended solution                                                                        

Formulation of question

The case at hand focuses on the question whether the Insurance Company should pay compensation for treatment expenses in a situation where the illness or its symptoms have started during the period of validity of the insurance policy but the treatment expenses have been incurred only after the expiry of the cover.

Applicable insurance terms

According to Finnish policy terms and conditions:

202.1.1 Korvaus hoitokuluista

Vakuutuksesta korvataan vakuutetun sairaudesta tai tapaturmasta aiheutuneita hoitokuluja siltä osin, kuin niistä ei ole tai ei olisi ollut oikeutta korvaukseen jonkin lain nojalla.-- Vakuutetulla katsotaan olleen oikeus korvaukseen, vaikka oikeus lain mukaiseen korvaukseen on menetetty vakuuttamisvelvollisuuden laiminlyönnin vuoksi.

Korvaamisen edellytyksenä on, että vakuutusturva on voimassa kulujen syntymishetkellä ja tapaturma on sattunut tai sairaus tai sen oireet ovat alkaneet vakuutusturvan voimassaoloaikana.

[The Insurance covers the expenses arising from the Insured’s illness or injury as they are not or would not have been compensated on the basis on any law. Compensation requires that the insurance cover is valid at the time of the occurrence of the expenses and the event has taken place or the illness or its symptoms have begun during the validity of the insurance cover.]

According to English policy terms and conditions:

This is a translation of the original terms and conditions in Finnish which, in case of discrepancies, take predence.

202.1.1 Compensation for Medical Expenses

The Insurance covers the expenses arising from the Insured’s illness or injury as they are not or would not have been compensated on the basis on any law. Compensation requires that the insurance cover is valid at the time of the occurrence of the expenses and the event has taken place or the illness and its symptoms have begun during the validity of the insurance cover.

Evaluation of the case

In this case, it is undisputed that A's illness or the symptoms thereof started when the insurance policy was in force. It is also undisputed that the validity of the insurance policy ended on 31 July 2015 as far as A was concerned.

The Insurance Complaint Board finds that the standard language-based interpretation can be taken as the starting point for interpreting the contents of terms of insurances of the person. Moreover, the Complaints Board notes that according to the interpretation rules of contractual terms, any unclear term should be interpreted with prejudice to the drafting party. These interpretation rules also require that the contractual terms must be looked at as a whole.

Moreover, the Insurance Complaint Board notes that it has been provided with the policy terms both in Finnish and in English. The two language versions differ in Subclause 202.1.1.  According to the Finnish version, the controversial sentence contains the word ’or’ while the English translation has the word ’and’. According to the English version of the policy terms, the Finnish insurance terms and conditions prevail in a situation of conflict of the versions. Furthermore, A’s claim is based on a translation compliant with the Finnish version of the policy terms. The Complaints Board evaluates the case on the basis of the Finnish version of the policy terms.

Under Subclause 202.1.1, the insurance will compensate for expenses caused by the illness or injury of the insured. The following sentence in the same paragraph defines the conditions for the compensability of treatment expenses. According to the sentence, compensation requires that the insurance cover is valid at the time of occurrence of the expenses. Moreover, the same sentence also contains the requirements related both to the occurrence of the event [injury] and beginning of the illness or its symptoms.

The requirements focusing on the occurrence of the event [injury] and beginning of the illness or the relevant symptoms during the validity of the insurance cover are contained in the sentence after the word “and”. The sentence ends with the words “during the validity of the insurance cover” which defines the requirements related to both events [injuries] and illnesses. The sentence would not make sense if the beginning of the illness or its symptoms during the insurance cover is deemed to constitute the condition of compensation, without requiring that the insurance cover must be in force at the time when the expenses are incurred. The requirement of compensation for the treatment expenses resulting from an illness is that the insurance cover is in force at the time when the expenses are incurred and that the illness or its symptoms have started when the insurance cover was in force. The contents of the Subclause mean that the insurer’s liability to pay indemnity for the treatment expenses coincides with the period during which the policyholder has the liability to pay the premium.

Based on the above grounds, the Insurance Complaints Board finds that the first paragraph of Subclause 202.1.1. of the policy term, when looked at as a whole, cannot justifiably give the impression that the payment of compensation would not require the validity of the insurance policy at the time of occurrence of the treatment expenses. The Complaints Board does not find that this point in the policy terms would be unclear. A does not have the right to have compensation for the treatment expenses for the period after 31 July 2015. The Insurance Complaints Board does not recommend that compensation be paid to A. The Complaint Board also underlines, for the sake of clarity, that the difference in the language versions of the policy terms does not have a bearing on the final outcome of the case at hand.

Final outcome

The Board does not recommend compensation.

The Insurance Complaints Board’s decision is unanimous.

INSURANCE COMPLAINTS BOARD

Chair Melander

Secretary Korkeamäki                                                                                                                                                                                              

Members:

Helenius

Kummoinen

Sario

Sibakov