Lloyd’s must pay disablement benefits after incorrectly denying a personal accident and sickness claim related to covid vaccine complications.
The claimant, a concreter, said the mRNA vaccine caused pericarditis, migraine and fatigue, and medical professionals confirmed he was unable to work.
The Australian Government has warned about the link between Covid-19 vaccines and myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the thin tissue surrounding the heart muscle), particularly in men under 40.
Research suggests the reaction is most common after the second dose and that it is more likely with Moderna than with Pfizer. However, the incidence rate is still very low and medical advice remains that the benefits of covid vaccines far outweigh the risks.
The claimant’s policy entitled him to a weekly benefit if he became “totally disabled” from working due to an injury or sickness.
But Lloyd’s denied his claim saying the disablement was related to a previous mental health condition and that it did not arise within 12 months from when his symptoms or illness began.
The man took his case to the Australian Financial Complaints Authority (AFCA), which found in his favour.
AFCA examined his “extensive medical record” in detail. The complainant had a first dose of a covid vaccine on October 8 2021 and shortly after experienced chest pain, shortness of breath, fatigue and headaches.
He was seen by many GPs, clinicians and cardiologists. Heart tests returned “normal” results, but AFCA says the “relevant doctors” were satisfied his chest pain was “most likely a Covid-19 vaccine-induced pericarditis”.
As a concreter, the ongoing symptoms prevented him from working, the doctors said.
“These matters establish the complainant’s total disablement began well within 12 months of the first vaccination dose or the onset of his disabling symptoms,” AFCA said.
AFCA says the insurer “appears to doubt the complainant has or had pericarditis”, and that even if he did, it would only have disabled him for two months.
Lloyd’s says the complainant has a history of mental illness since 2006 and that the symptoms relate to “mainly an anxiety-related condition”.
But AFCA says although one doctor asserts the complainant’s symptoms are due to prior mental health conditions, this doctor never examined the patient and there is no evidence the previous conditions are ongoing.
His last pre-policy issue with mental health “appeared to be in 2016”, AFCA says.
It also says the expert doctors do not agree with Lloyd’s belief that if the man had pericarditis he could return to work after two months, quoting one as saying a gradual recovery is expected over a six month period and that recovery is “highly variable” between individuals.
“Even if I accept the complainant currently has an ongoing mental health condition, there is no evidence it is the cause of his disablement,” the AFCA ombudsman writes.
“No treating doctor has ever suggested this, and there is simply no evidence of this in the complainant’s extensive medical record.
“I am satisfied the complainant is entitled to cover for his disablement.”
AFCA says the insurer must pay all unpaid weekly benefits and all costs incurred to obtain medical reports in relation to the dispute.
It also says Lloyd’s must pay $3000 compensation because the claim was not fairly assessed.
“In justifying their conclusions, the insurer and [one doctor] have made statements to the effect that the complainant’s treating doctors had considered his condition to be ‘anxiety-related’,” AFCA said.
“They have not identified the relevant doctors that said or suggested this, and I was unable to find any doctor that said this in the complainant’s extensive medical record.
“Such statements are simply untrue and have contributed to the claim being unfairly and unreasonably declined.
“The consequence of this to the complainant was that he was unfairly deprived of policy benefits for almost the full benefit period [and] it added to the stress and inconvenience he was already experiencing with no income.”
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