Insurer denies Auckland mum’s breast cancer claim over earlier ‘mastitis’ symptoms

“I think if you’re going to provide people health insurance then you should show up when they need you, especially when you make that much money. It’s not like insurance companies are skint.”

The Auckland high school teacher wants other mothers to check with insurance companies before they sign up, about whether their breastfeeding history and mastitis symptoms would be an issue if they are subsequently diagnosed with breast cancer.

Weir has exhausted her third and final avenue to appeal the insurer’s internal decision to reject cover, but she hasn’t given up yet, and plans to file a complaint with the Insurance & Financial Services Ombudsman Scheme.

AIA chief customer officer Maddie Sherlock said the insurer was sorry for what Weir was going through and was not questioning her integrity, but her claim was declined in line with the terms and conditions of her policy.

Sherlock said Weir had experienced breast-related symptoms which she was “required to disclose’ for several weeks before her policy commencing, that led to further testing and a cancer diagnosis.

Because of the “clear link” between pre-policy symptoms and the later diagnosis, the pre-existing condition exclusion applied which she was “required to disclose’ – “regardless of whether the underlying condition was diagnosed or suspected at the time”.

“We recognise this is a very difficult situation for Sophie, and we understand she may wish to have the decision independently reviewed.”

Weir first approached a financial adviser about getting health coverage for herself and her family on October 1 last year, five months after giving birth to her youngest child.

“It was just like, ‘Oh, we’ve got a couple of kids, I should probably look into that’. It seems like a smart thing to do if something went really wrong with our kids.”

Shortly after, the adviser provided options for coverage, and late the following month, on November 27, her application for coverage at AIA insurance was approved and coverage began.

The following week, on December 1, she attended a GP appointment after experiencing weeks of breast engorgement in her right breast, a common issue for breastfeeding mothers.

Notes shared with the Herald by Weir show the doctor wrote she had presented with a breastfeeding complaint and had experienced pain in her right breast for two days, engorgement for five weeks and showed mild redness.

She told the Herald she had never noticed the redness and said the five weeks were a rough estimate.

The notes said no specific lump or abscess was identified, and the GP’s impression of her condition was “lactational mastitis”. Weir was prescribed antibiotics.

She also spoke to a Plunket worker about her breast on November 28. Notes from the call said she had experienced pain on one side for five weeks.

“Baby is six months but maybe not totally emptying the breast and will only feed for 10 minutes,” the Plunket worker wrote.

They also noted Weir was not sure if her baby was getting enough milk from that breast or whether this was something she should raise with her doctor.

It was recommended that she start feeds on her sore breast as the baby sucked strongest on the first side.

The worker recommended commencing a gentle breast massage toward the nipple during feeding, using a cold pack and trying different feeding holds.

Checking for latching issues, using pain relief and a warm shower if needed, were also recommended.

If symptoms worsened she was advised to see her GP.

Weir said these were common strategies to prevent mastitis from developing.

“What often happens is that you have a blocked duct, which is what I thought was happening, and that can develop into mastitis.”

Weir felt she did not need to worry; she knew her breast engorgement symptoms were common and she’d seen lactation consultants who had not raised any concerns.

However, when her breast symptoms had still not settled four days after her GP appointment, she was referred for an ultrasound because her mastitis was not responding “as expected” and she had a “possible abscess”.

Two days later, on December 7, she visited a hospital emergency department after feeling unwell and a doctor there did not believe it was mastitis and escalated her care.

“No one said the C-word, the doctor just said, ‘You need an urgent mammogram’, then I read between the lines.

“I acted on it right away, it wasn’t like I was scared of getting results or avoiding the diagnosis. I was like, ‘Oh no, if it is cancer I want to know right away’.

“I just had this gut feeling and it sucked because my mum picked me up from ED that day and I looked at her and I just said, ‘I’ve got to get a mammogram’, and we both kind of teared up and knew.”

About two weeks on from her initial GP appointment, it was confirmed. She had breast cancer.

The lump was 10cm by 6cm.

“It was massive. When you think about the size of that, it’s not like a little lump, it’s a large mass. So when you’re pressing around your boob looking for a lump you probably wouldn’t feel it anyway because it’s so big.”

She started chemotherapy on New Year’s Eve 2025 and after completing her sixth round, she underwent surgery to remove her breast this week.

Weir said she first learned there could be an issue with her insurance coverage when she notified her financial adviser that she was having tests.

“Oh I think I’ve got something serious on my hands,” she told the adviser about the time of the mammogram.

“She was like, ‘Yikes, the timing’s not great’,” and indicated there could be a problem.

While Weir is now being treated in the public system, she went through the diagnosis process, her initial round of chemo and received some medication privately, setting her family back about $35,000.

A Givealittle has now been launched to help cover the costs.

“I just always thought, ‘Oh well, we’ll argue our case’. I know that I’m honest, I’m not trying to fudge the system, so eventually it will be fine.”

Weir feels lucky that her family have had a lot of support outside of their insurance company, but said the situation with AIA felt unjust.

The coverage denial had made her feel “more passionately” about advocating for breastfeeding women, especially when women were being encouraged to breastfeed their babies.

“It feels like another reason people will say, ‘I don’t want to breastfeed’.”

She fears other women who previously had mastitis may not be covered if they are subsequently diagnosed with breast cancer and have not disclosed earlier symptoms.

Because breast engorgement is a common occurrence for breastfeeding mothers, Weir doesn’t know what more she could have done.

“It’s not a symptom when you don’t know that you have cancer. It’s maybe a symptom in hindsight but it doesn’t feel right to call it a symptom when it’s part of being a breastfeeding woman.”

Another point raised by the insurance company was that Weir had not informed AIA that her sister had also previously had breast cancer.

Weir said it slipped her mind because it was DCIS breast cancer, which was not genetic.

“She got tested for genetics ... I think that’s the one mistake I made that I’ll own, but it was never genetic anyway.”

Weir believed AIA was “finding any way to win the case” because of the “unfortunate” timing of her policy.

“But it’s unfortunate timing for everyone, I didn’t ask to have cancer.”

Sherlock said AIA did not automatically treat breastfeeding-related conditions, such as breast engorgement, as grounds to decline eligibility for breast cancer cover.

“Each application and claim is considered on its individual circumstances, based on the full medical evidence and the terms of the policy.

“For the pre-existing condition exclusion, the key consideration is not a specific label like ‘engorgement’ or ‘mastitis’, but whether symptoms were present prior to cover starting and whether those symptoms are connected to the condition being claimed for.”

In this case, Sherlock said the medical evidence showed a clear continuity between symptoms experienced before the policy began and the condition subsequently diagnosed.

Even if Weir had disclosed the symptoms she was experiencing, Sherlock said she would have been subject to a three-month temporary exclusion from coverage for both breasts.

“Unfortunately, as the diagnosis occurred within that period, the claim would not have been payable in any event.”

Sherlock noted the exclusion policies were common among insurers, clearly outlined at the time the policy was signed and applied consistently across all customers.

University of Auckland Professor of Surgery John Windsor wrote a letter to AIA regarding Weir’s situation.

“The first issue is that you claim that breast cancer is a pre-existing condition,” Windsor wrote. “Of course it is. A cancer always exists before it is diagnosed.”

He said that if Weir thought she had breast cancer and was being dishonest, she would not have delayed her insurance application process, which began at the start of October.

The second issue was that her presenting symptoms were those of engorgement and lactational mastitis, Windsor said.

“That was the entirely plausible diagnosis by her GP. The presenting symptoms were not typical of breast cancer, and indeed, those symptoms made it more difficult to diagnose breast cancer.”

Windsor wrote that he had known Weir for more than a decade and her character was one defined by integrity.

“She lives by her values in all the roles she plays – loving mother and wife, supportive friend, passionate high school teacher, active and giving member of church and community groups.”

Sherlock said AIA respected Windsor’s experience and acknowledged his perspective on the matter, but “at no point have we questioned [Weir’s] integrity”.

“Our assessment does not include assumptions about intent or character. Rather, it is based on the policy wording and the medical evidence available, including the timing and nature of symptoms prior to the policy start date.”

An insurance expert spoken to by the Herald empathised with Weir but said the circumstances did not appear to support her claim.

“Sometimes people get ‘fortunate’ with the timing of their insurance, where they take out cover, and soon after have a situation where they have a claimable event. Others may have had the same cover for 20 or 30 years and never have a claim.”

Weir’s kids still don’t understand fully what their mother is going through, but they know she’s sick and that sometimes their mum is “really tired”.

“You’re trying to protect your children from worrying for you.”

With her students in the classroom, things are different. She can’t hide the fact that she looks different and she’s wearing a wig.

She has a “little monologue” she shares with her classes, explaining why she is off work so much and what she is going through medically.

But she reassures her classes that she will be fine, and “my problem is not your problem”.

“I’d rather you be optimistic with me than worried for me,” she tells them.

Even if her Ombudsman complaint is unsuccessful, she believes going public with her story is essential so other women know about her experience and how it could impact them.

“Check what your provider’s attitude is towards women’s health.

“This is a human rights issue. It feels bigger than getting money off an insurance company.”

Katie Harris is an Auckland-based journalist who covers issues such as sexual assault, workplace misconduct, media, crime and justice. She joined the Herald in 2020.

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