A man who had symptoms of illness before he cancelled his policy was entitled to a payout, the financial services ombudsman has ruled.

He was diagnosed with multiple sclerosis (MS) after he stopped his trauma cover, and Zurich denied his claim on the basis there was no diagnosis and he did not have more than one episode of “neurological deficit” while insured.

But after reviewing doctors’ evidence, the Australian Financial Complaints Authority has ruled the man had undiagnosed MS while the policy was in place.

The policyholder has died and his beneficiary under the cover, his executor, complained to the ombudsman.

The man had trauma cover from August 2011 until August 2020. In February 2021 he was diagnosed with MS and made the claim.

The policy did not require diagnosis during the period of cover, and he did have more than one episode of neurological deficit, the ombudsman has ruled.

A neurologist who saw the man in December 2020 was confident the MS developed around March or April 2019.

The ombudsman says many MS patients have vague symptoms that can be attributed to other medical conditions.

Zurich argued the policy terms required an unequivocal diagnosis during the coverage term, but the ombudsman says this is not a correct interpretation of its policy.

A person does not need insurance for a diagnosis of MS or other conditions, “they need insurance for the condition itself, for the serious impact MS may have on their life”, AFCA says.

Read the determination here.