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Woman sues Prudential, saying insurer used 'buried clause' to deny S$100,000 brain surgery claim
The woman alleges that Prudential "manipulated" the language of the contract "with the sole purpose to make financial gains", but Prudential says her condition was clearly excluded in the policy document.
A view of the State Courts building in Singapore.
SINGAPORE: A 45-year-old woman is suing insurer Prudential Assurance Company Singapore, seeking a payout of more than S$100,000 (US$78,345) for brain aneurysm surgery she had in 2023 after suffering a stroke.
Ms Cai Yunhong had a stroke in 2023 from a ruptured aneurysm and underwent endovascular repair, which is not covered under the policy she purchased.
The unrepresented woman alleges that Prudential denied her claim in September 2023 because of a "single, buried clause" that defined brain aneurysm surgery as only the open-skull procedure of surgical craniotomy, a procedure she said was riskier and more invasive, with higher mortality rates.
Ms Cai claimed that Prudential "manipulated" the language of the contract "with the sole purpose to make financial gains".
Prudential, which is being defended by Mr Joavan Pereira from Virtus Law, said in its opening statement that Ms Cai's claim was "meritless" as the contract stated unequivocally and unambiguously that the type of surgery Ms Cai underwent would not entitle her to payment of the lump sum benefit she was seeking.
The trial opened on Wednesday (Mar 18) with Ms Cai tendering her affidavit before being cross-examined by Mr Pereira.
MS CAI'S CASE
According to documents tendered by Ms Cai, she purchased an early critical illness policy from Prudential after being approached by Standard Chartered Bank in 2016. This was the Prulife Multiplier insurance policy with financial protection against death, disability, terminal illness and critical illness, with an early crisis cover multiplier supplementary benefit that provides a higher payout."I was 35 at the time, and had no medical history. I was also told that the Prudential (policy) was one of the most premium products and offered the widest coverage that was available in the marketplace," said Ms Cai in her statement of claim.
"This was the promise I bought into, and it was only later I found out that (the) product contract did not reflect this intent," she said. She also claimed that the exclusions to the medical conditions, other than exclusions for pre-existing conditions, were not explained to her during the sales process.
In 2023, Ms Cai suffered a stroke from a ruptured aneurysm and collapsed while she was taking a bus. She was taken to hospital by ambulance, with an emergency operation being performed by the head of neurosurgery at the National University Hospital, her statement of claim stated.
Ms Cai spent 21 days in hospital, including eight days in the intensive care unit. She said in her opening statement that she had recovered "miraculously well" and that many patients with her condition do not survive, or they have neurological deficits that leave them unable to work for extended periods.
Ms Cai claimed that she was not given a choice in terms of what type of surgery would be performed. She said she later discovered that Prudential's policy makes payouts only in instances where a brain aneurysm is treated via a surgical craniotomy – a procedure where part of the skull is removed to reach the brain.
She had undergone endovascular repair instead, which she said was the modern, minimally invasive and evidence-based first-line treatment for her condition.
Ms Cai said she found out only after her illness that rival insurers had "a fairer approach" when defining the condition of brain aneurysm, by not specifying the need for a particular type of procedure to have taken place.
She argued that Prudential had "purposely misled the unassuming public, selling the insurance under false promise of protection for brain aneurysm".
She is seeking the full claim amount of S$108,500 under the early crisis cover multiplier, with accruing interest, as well as a refund of two years' premiums paid in 2023 and 2024 and a waiver of the remaining premiums under the policy. The latter sums come up to about S$12,000.
"I cannot imagine what another person would do in my shoes – say someone who is later in age, suffering a stroke in their 50s or 60s, losing the ability to work, unable to collect on their policy payments, and not in a position to take Prudential to court," said Ms Cai in her opening statement.
"What happens to them? They suffer in silence. They lose their savings. They lose their dignity. They lose the security they thought they had purchased."
She said she was filing this suit in hopes that no one will have to do the same, adding that her efforts will not be in vain if her case can shine a light on "these unfair practices", "force insurers to be transparent about their exclusions" and "remind them that they have a duty of good faith that must be honoured".
PRUDENTIAL'S DEFENCE
Prudential said in its opening statement that Ms Cai's case was that the payment should be based on the confirmation of the diagnosis and not the treatment, despite the express terms of the contract."In essence, Ms Cai’s case is that the terms of the contract between the parties ought to somehow be what she likes them to be, as opposed to what had been expressly agreed in writing between the parties. This position is without any legal or factual basis whatsoever," said Prudential's lawyers.
They added that Standard Chartered had specifically brought to Ms Cai's attention a section in the benefit illustration and product summary of the policy which set out the definitions of the medical conditions, which would entitle Ms Cai to payment of the early crisis benefit.
The definitions were explained to her in a face-to-face meeting before a proposal was submitted to purchase the insurance policy, said Prudential.
The insurer's lawyers said they would demonstrate at trial that none of the alleged representations to Ms Cai about the policy, if they were even made, amounts to actionable misrepresentation.
Prudential said her allegations about the supposed litigation tactics are "untrue and baseless" and irrelevant to the subject of her claim. Certain proceedings were commenced because Ms Cai had failed to make payment of costs orders, and the court had already stated it was not prepared to find that Prudential had employed any illegitimate tactics.
Prudential said it was Ms Cai who expressed an interest to her relationship manager at Standard Chartered at the time, Mr Joseph Chen, to find out more about life insurance policies with critical illness coverage.
Mr Chen then had a conference call with Ms Cai and a Mr Tan Kwang Hui from Standard Chartered. The two men from the bank suggested the Prulife policy to Ms Cai, as Standard Chartered had a partnership with Prudential.
In an email Mr Tan sent to Ms Cai in early August 2016, he specifically highlighted a section setting out the definitions of critical illnesses that would entitle her to payment.
Under brain aneurysm surgery, it was stated that this is defined as the actual undergoing of surgical craniotomy with certain aims, and that endovascular repair or procedures are not covered.
Mr Tan also sent Ms Cai another email later in August 2016 similarly setting out the scope of medical conditions that would entitle her to payment of the early crisis benefit.
Prudential said Mr Tan subsequently took Ms Cai through a hard copy of the benefit illustration and product summary and explained every page, including the scope of medical conditions which would entitle her to the payment.
He also explained the stroke category, the definition of brain aneurysm surgery and the fact that any procedure not within the listed definitions would not be covered. Ms Cai did not raise any concern about not being able to understand the contents of the final benefit illustration and product summary, said Prudential. She signed the first 10 pages as acknowledgement.
Prudential said the policy document "made it very clear" that endovascular repair was specifically excluded from the definition of brain aneurysm surgery.
It rejected Ms Cai's allegation that Prudential was a "market outlier", calling this "disingenuous and false", as other insurers structure policies for brain aneurysm surgery the same way.
It is Prudential's prerogative as to how it wishes to structure its products and coverage and it is not the only insurer, whether in 2016 or currently, to exclude coverage for endovascular surgery, said lawyers for the insurer.
In any case, up to Aug 17, 2016, Prudential did not have any dealings with Ms Cai as the entire sales process was carried out by representatives from Standard Chartered, said Prudential.
It has asked for the claim to be dismissed with costs.
The trial continues.
