A travel insurer has been ordered to pay an overseas dental claim after the industry ombudsman found the insurer’s own medical expert had disputed the basis for denial. 

The complainant sought reimbursement for $US1700 ($2387) in dental expenses under her policy, after experiencing sudden, severe pain caused by an infection.  

AWP Australia's policy covered overseas dental treatment provided it was to healthy, natural teeth and was solely for immediate pain relief.  

AWP declined the claim, arguing the treatment involved root canal therapy and the removal and replacement of a bridge.

It said this procedure is restorative or reconstructive treatment, which is associated with deterioration and decay, and not limited to emergency pain relief. The insurer also excluded any claims related to damaged bridges. 

The woman’s treating dentist said she had presented with a sudden, acute pulp infection and severe pain, with no prior symptoms, diagnosis or decay affecting the teeth. Root canal treatment was required to relieve the pain and treat the infection. 

AFCA found that the insurer’s own clinical medical officer (CMO) did not support its position. The CMO’s advice stated that root canal treatment was an endodontic procedure intended to clear infection, rather than restorative or reconstructive treatment, and that root-canalled teeth could still be considered natural teeth. 

The advice also indicated the claim could meet the policy definition of acute pain involving natural teeth. 

AFCA noted that the CMO advice appeared to have been received after the insurer’s decision to decline the claim, raising questions about whether the original decision had been informed by that advice. 

The ombudsman also rejected AWP’s reliance on the bridge exclusion, finding the bridge had to be removed to access and treat the infected teeth. Its replacement was therefore part of the covered emergency dental treatment, rather than an unrelated claim for damage to a bridge. 

AFCA said: “The insurer’s decision to decline the claim was not justified, and it did not adequately respond to the complainant’s concerns which may have identified this mistake earlier. This caused avoidable stress and frustration. It should pay $1000 in compensation for this.” 

Click here for the full ruling.