Traveller trips on insurance technicality

Josette Maeyer has learnt a hard, expensive lesson and will be more wary of a sales pitch.

This after the Vredehoek resident stepped into a pothole at Malta Airport when she was returning home and broke her foot.

But Travel International Consultants (TIC) wouldn’t pay her medical expenses because she was treated in South Africa and not in the country where the injury occurred.

“Last year my husband and I took out a travel ticket to the USA with Flight Centre in Sea Point and we then asked for insurance cover to protect us against any unforeseen accidents or health issues that may require hospitalisation or doctor treatment. My husband told the agent we would be with a tour group in Malta before the American trip and wanted cover from the day we left for Malta to the day we returned from America. Their travel agent told us it was possible even though we will be back in SA for 11 days before we left for America,” Ms Maeyer said.

“As I was stepping out of the car at Malta Airport I stepped into a pothole and broke my foot. I did not realise at the time it was broken although it was extremely painful. The only choice I had was to continue on my journey home. When we got home I went to MediClinic where they found that it was broken. On my return from America I claimed R7 679.22 from TIC for this injury but they rejected it because I did not have it attended to in Malta,” Ms Maeyer said.

She told TIC why it was not possible: they were not permitted to leave the travel group in Malta; she did not know that her foot was broken; she knew she would have it seen to in South Africa and the agent made sure they were covered for the whole trip, including the 11-day stay-over at home, and they paid for it.

“I have tried to sort this out and feel that I have been misinformed by the agent even though he confirmed what the cover was for. The agent no longer works at Flight Centre,” Ms Maeyer said.

“I hope you can assist me as my dealing with TIC has been fruitless.”

Even though Ms Maeyer alleges she and her husband were misled by the agent, the onus is on them to read the contract and if they didn’t understand to ask and ask again, until they did, which is their right under the Consumer Protection Act.

While the TIC policy is not as clear as daylight, it should state clearly why they will not countenance a claim if the injury is not attended to where it happened.

Melody Makeka, spokesperson for TIC, which is underwritten by Santam, said they repudiated Ms Maeyer’s claim in line with the legislative framework they operate in. “Ms Maeyer claimed for the reimbursement of medical expenses incurred in South Africa following an injury she sustained in Malta. The policy operates on the basis that it will cover emergency medical expenses incurred, whether injury or illness, while travelling outside the borders of South Africa. We acknowledge that the incident occurred outside the country, however the expenses incurred within South Africa.”

All travel insurance policies were amended to be compliant with the Demarcation Regulations, which prohibits a short-term travel insurance policy from covering expenses incurred within South Africa. (The regulations were amended to prevent medical aid and insurance fraud).

Ms Makeka confirmed that if Ms Maeyer had attended to the injury in Malta, TIC would have paid for the extra expenses, including tickets, she would have incurred, as the policy covers events that occur while on a journey outside the borders of South Africa.

“TIC is bound by the Demarcation Regulations (Section 70 of the Short-term Insurance Act) that does not allow us to pay medical costs incurred within the borders of South Africa irrespective of the circumstances and as such we are not in a position to contravene the prevailing legislation,” Ms Makeka said.

However, Ms Maeyer was not satisfied with the explanation, as she says she was led to believe that the policy covered her for the entire period.

The TIC document wasn’t entirely in plain English, although I understood why they rejected Ms Maeyer’s claim.

Ms Makeka said the policy states, “We will insure you for the benefits subject to the terms and Limits of Liability while on an International Journey. The Schedule of Insurance and policy wording must be read together as one document” .

“The reimbursement to the policyholder or to a medical institution is dealt with under Section 1 of the Schedule of Insurance. There is no mention of any benefit for the reimbursement of medical expenses in your home country, in this case, South Africa. Historically this was allowed but TIC along with all travel insurers in South Africa had to remove this benefit from the policy because it was deemed in conflict with the Demarcation Regulations that came into being a year ago in January. TIC added an endorsement to explain to the policyholder that the benefit was no longer allowed,” Ms Makeka said.

That explains it. But I still believe TIC (and other insurance companies) should explain their policies in plain English: TIC should spell it out: “If the injury occurs outside the borders and you have it treated in South Africa we will reject your claim”.