Claim declined over ‘four drinks’

The travel insurance claim of a woman who stopped breathing after a night of drinking and dancing in Mexico, has been declined.

Her friend took their case to Financial Services Complaints Ltd, a disputes resolution service that hears complaints about financial service providers.

The woman had had knee surgery and was prescribed codeine for the pain. She and a friend were out for a night drinking and dancing when her knee started to hurt, so they went back to where they were staying. She took a couple of pills and went to sleep.

But her friend said that, soon after, she let out a big sigh and stopped breathing. He called for help. She was taken to the hospital and given oxygen and a drip in the ambulance. She started to breathe by herself but was still having difficulty. The hospital told her friend it would cost US$8000 (NZ$12,460) to put her in intensive care.

While he rang the insurer, the woman discharged herself from hospital. The pair later received a medical bill for the cost of consultation and care. They made a claim to their insurer but were denied.

The insurer said its insurance policy clearly excluded claims arising ‘‘directly or indirectly’’ from alcohol consumption.

The insurer relied on ambulance and hospital documents that recorded the woman was intoxicated and had taken codeine.

The friend said he purchased travel insurance for peace of mind. He argued it was unfair that he saved the woman’s life but the insurance company still would not pay.

He said the woman was not intoxicated, and the insurer was wrong to rely on the medical documents from Cancun. There was no blood test, so the insurer could not rule out codeine as the principal cause of the symptoms, rather than alcohol. However, he said the woman had consumed about four drinks on that day, and they had been drinking and dancing. FSCL said the insurer had relied on a poor translation of the medical documents.

‘‘However, we agreed with the insurer that [the man’s] policy did not cover [the woman’s] medical costs. This was because she had told us she had been taking codeine for approximately one year without any side-effects.

‘‘However, on this occasion she had suffered severe side-effects after she had also consumed alcohol. In our view, it was most probable her symptoms were caused by a combination of alcohol and codeine, rather than codeine alone. As we did not have any blood tests from the hospital to tell us what her blood-alcohol level was, we made our decision on the balance of probabilities, and [the man’s] admission.’’ The complaint was withdrawn. FSCL does not identify the parties in its cases.