A Discovery Bay couple have been landed with a bill for nearly HK$300,000 after their health insurance company refused to pay out on their medical claim, even though they have the support of doctors. 'It's tough financially and emotionally. We really are running out of options,' Andy Baumgaertner said. His wife, Julie, was admitted to Matilda International Hospital on The Peak suffering from severe abdominal pains. Their insurance company, GlobalHealth Asia, issued a letter of guarantee to the hospital on the same day, assuring the couple that they would cover all costs. At that time the cause of the pain was unclear. After several tests, doctors found an infection in her intestines and a perforation in her lower abdomen, but the root cause of the problem remained unclear until Julie had undergone surgery. It was then diagnosed as an infected and perforated Meckel's diverticulum. When Julie was discharged on May 28, the hospital said it would handle payments directly with GlobalHealth. But on June 10 she received a rejection letter from GlobalHealth stating that her condition was a birth defect and therefore not covered under the policy. In a letter to the Baumgaertners, GlobalHealth stated: 'A Meckel's diverticulum is a true congenital diverticulum, it is a small bulge in the small intestine present at birth.' For this reason they refused to pay as 'tests and treatments related to ... birth defects, congenital conditions ... and consequences thereof ... will not be covered'. They attached the invoice from the hospital and asked her to settle the bill (HK$287,401) with them directly. Despite letters of support from a general practitioner and a surgeon, the Baumgaertners' claim has been rejected three times. 'Doctors have told us that we are not liable and we could take the case to court, but that will involve more money and it's not certain we'll win the court case,' Mr Baumgaertner said. 'What is so frustrating is that we have medical backing that we are in the right, but the insurance company refuses to acknowledge this. It has been a very stressful time.' Chartis Insurance Hong Kong, the underwriting company for GlobalHealth Asia, is now evaluating the case. Because they were not involved in the original events and exchanges between Mrs Baumgaertner and GlobalHealth Asia, they say they do not possess all the details of the case. Des Walsh, Chartis Insurance Hong Kong's vice-president for claims, said: 'In order to provide an accurate answer ... we have initiated a review of the facts and details that led GlobalHealth Asia to make the decisions they did. We expect that this process will take about two weeks.' Congenital means present from birth, explained Baumgaertner's surgeon, who spoke on condition of anonymity. Not everyone develops a problem in a previously normal structure, but they buy insurance to protect against such an eventuality. 'A Meckel's is a normal intact structure found in 2 per cent of the normal population. It does not always give rise to a medical problem but it may,' the surgeon said. 'It is universally recognised as a condition covered by medical insurance.' The Baumgaertners' general practitioner, who for professional reasons also remained anonymous, agreed, saying that although a Meckel's diverticulum was a very common congenital anomaly, and that an operation on a Meckel's per se was excluded by GlobalHealth's insurance terms, 'infection and perforation of a Meckel's is not a congenital condition'. 'It was the infection, not the congenital abnormality, causing her obstruction,' he said. 'Or if you want to use an analogy - being red-headed is congenital. Red-headed people are predisposed to skin cancer. Would you deny the claim of a red-headed person who developed skin cancer?' A surgeon contacted independently by the Sunday Morning Post, and not associated with the case, also agreed with these opinions.
