PZU Życie SA introduces a new definition of chemotherapy in its general terms and conditions of insurance (GTCI). This is the result of the actions taken by the President of Office of Competition and Consumer Protection.
The Office of Competition and Consumer Protection (UOKiK) has received a complaint from a consumer whom PZU Życie SA has refused to reimburse the costs of chronic lymphocytic leukemia therapy, although he had acquired a policy for specialist treatment. The insurer explained that, according to the definition contained in the GTCI, chemotherapy covered only treatment with parenteral anticancer drugs, and the patient in question took them orally. The case raised doubts of the President of UOKiK, who instigated explanatory proceedings and asked the company to change its practices. As a result, PZU Życie will change the definition of chemotherapy in the GTCI that are the subject of the proceedings for one that is more favorable for consumers, and will also enable the pursuit of claims by the persons it issued a negative decision to after 1 January 2017.
“Medical definitions included in the general terms and conditions of insurance must be clear and unambiguous. They cannot narrow down the concepts of a disease or a therapy. One must remember that it is the doctor that decides about the method of treatment each time. If a doctor decides that orally administered drugs will produce the best results in a given case, this cannot be a reason for the refusal of payment of the benefit. Thanks to the fact that PZU Życie company will change the definition and take into account the claims of the injured consumers, it will avoid having charges brought against it,” says Tomasz Chróstny, President of the Office of Competition and Consumer Protection.
The President of Office of Competition and Consumer Protection already dealt with a similar case in 2010. At that time, doubts were raised by the definition of a heart attack applied by PZU Życie, on the basis of which the company refused to pay compensation to many patients. Following consultations with cardiology experts, the President of OCCP stated that the definition did not correspond to the existing medical knowledge. In the event of a heart attack, the condition mentioned by PZU Życie in the GTCI – the Q wave on the ECG – did not have to occur. The fine of almost PLN 4 million for misleading consumers was upheld in 2013 by the Court of Appeal.
