About medical insurance cover

**I pay $300 a month for medical insurance and presumed it would cover anything I was advised to do by my doctor. I had breast cancer and a mastectomy. Then, a year later, my surgeon told me I needed a second mastectomy as I had a 50% chance of getting cancer in the other breast. But the insurance company refused the claim, saying the fine print prohibited “elective surgery”. The fact my doctor said it was necessary didn’t sway them.

Charlotte, via email

I’m on your side. “Elective” doesn’t simply mean you have an option whether to have the operation or not. If that were the case, all operations would be “elective”. Surely it means there is a reasonable choice available to you as to whether you have the operation or not. If the doctor is saying that you have a 50% chance of getting cancer in that second breast, then it would seem only sensible you have it removed. I’m sure you don’t want to do it, but you have no choice. It’s difficult to know whether the insurance company is breaching their contract with you because I don’t have the conditions in front of me. More likely, they have included a quite unreasonable clause which they are sticking by. Of course, you won’t have noticed it because who reads through all the small print of a medical insurance contract prior to needing to claim? I recommend you take this matter up in the strongest manner with the CEO of the insurance company. If that doesn’t work, get a lawyer to check it out. If you can’t afford that, go to Fair Go, Campbell Live or Close Up. If that doesn’t work, put in a claim to the Insurance Ombudsman – but your chances of success there are not high. I wish you the best.

Do you have a consumer question for Kevin? Email [email protected], or post to Weekly Consumer, PO Box 90119, Victoria St West, Auckland 1142.