Can an insurance provider reject a claim under an insurance policy on the basis that the deceased was allegedly aware of his illness within 90 days of buying his policy?
OOI CHENG CHENG (AS ADMINISTRATOR AND REPRESENTATIVE TO WILSON TAN TECK HOOI, DECEASED) V AXA AFFIN GENERAL INSURANCE BERHAD  1 AMR 243
- Ooi Cheng Cheng (“Mrs Tan”) is the wife of one Wilson Tan Teck Hoi (“Deceased”).
- The Deceased had taken out a “Cancer Plus Plan 150K” (“Policy”) from AXA Affin General Insurance Berhad (“AXA”) on 1 November 2012.
- The Policy contained a clause which stipulates that AXA is not liable to pay out on the Policy where the insured has “cancer for which the insured person gets medical advice, has symptoms, or tests, or received any medication or treatment within 90 days from the date such insured person was first covered under this policy” (“Clause”).
- On 3 April 2013, the Deceased was diagnosed with cancer and passed away on 4 June 2013. Mrs Tan then sought payment of the insured sum under the Policy.
- Relying on the Clause, AXA rejected the claim by Mrs. Tan.
- AXA claimed that the symptoms of the Deceased’s lung cancer had started around January 2013, i.e. within 90 days of the date of the Policy. Therefore, under the Clause, AXA was entitled to reject the claim by Mrs. Tan.
- Mrs Tan filed a claim for payment of the insured sum and a declaration that the Clause was against public policy, law and equity and is therefore void and unenforceable.
- The High Court dismissed Mrs. Tan’s claim. Mrs Tan appealed to the Court of Appeal.
COURT OF APPEAL DECISION – APPEAL ALLOWED!
The Court of Appeal allowed the appeal on the following basis:
- The plain meaning of the Clause will mean that the Deceased knew that he had cancer or at least when he approached for medical assistance or professional help, he knew that he had symptoms or asked to do tests or received medication for cancer.
- Therefore, the Deceased must have suspected that he had cancer and the key word is “cancer”.
- On the facts of the case, AXA could not reject the claim because none of the medical personnel who had seen the Deceased during the period, complained of or knew that the Deceased’s ailment had anything to do with cancer.
- AXA also did not adduce evidence of any person who had attended to the Deceased within 90 days of the inception of the Policy to deal with any issues related to cancer. Therefore, there was no positive evidence adduced by AXA to warrant the rejection of the Policy.