Critical & Serious Illness Decision Reference 2024-0047

Year2024
Reference2024-0047
Date28 March 2024
Subject MatterCritical & Serious Illness
Finantial SectorInsurance
Conducts Complained OfClaim handling delays or issues,Rejection of claim - non-disclosure & voiding
Decision Ref:
2024-0047
Sector:
Insurance
Product / Service:
Critical & Serious Illness
Conduct(s) complained of:
Claim handling delays or issues
Rejection of claim - non-disclosure & voiding
Outcome:
Rejected
LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN
The Complainants incepted a dual life Protection Insurance Policy with the Provider on 1
April 2020, for a term of 12 years. The policy provided life cover benefit of €140,160.00 for
the First Complainant and €84,960.00 for the Second Complainant, as well as providing
both with standalone serious illness benefit of €25,000.00, for a monthly premium of
€94.12.
The complaint concerns the Provider’s decision to decline the serious illness claim that the
First Complainant made in September 2020 and remove her from the policy, due to what
it said was the nondisclosure of material facts, relating to her medical history when
applying for the policy. The Complainants cancelled the policy with effect from 30 June
2022.
The Complainants’ Case
The First Complainant was diagnosed with invasive lobular breast cancer on 23 June 2020.
The First Complainant completed a Serious Illness Claim Form to the Provider on 1
September 2020, advising that she had first consulted her GP on 26 April 2020 (the GP
notes this date as 24 April 2020 in the Private Medical Attendance Report to the Provider)
regarding symptoms of “breast tenderness & changes” that had first commenced in
January 2020.
- 2 -
/Cont’d…
The Complainants say that following its assessment, the Provider wrote to them on 16
March 2021 to advise that it was declining the First Complainant’s claim as she had failed
to disclose material facts relating to her medical history when completing the Application
Form on 6 March 2020 and to tell them that it was also removing her from the Protection
Insurance Policy.
The Complainants say that at the time they applied for the Protection Insurance Plan with
the Provider in March 2020, they held a similar policy with a different insurer that was
providing the First Complainant with the same amounts of life cover and serious illness
benefit and that their reason for seeking to move insurers was that the Provider was
offering the same level of cover at a cheaper rate.
The First Complainant says that she did not know she had lobular breast cancer when
applying for insurance with the Provider in March 2020 as she was not diagnosed with this
condition until 23 June 2020.
The First Complainant says that having had minor symptoms of breast tenderness for two
months, she attended her GP on 26 April 2020, who advised her that although she thought
the symptoms to be something hormonal, she was, just to be certain, referring the First
Complainant to the Hospital Breast Clinic for a routine review.
The Complainants note in this regard that when completing the National Breast Referral
Form to the Hospital Breast Clinic, the GP described the First Complainant’s referral as
“Routine – to be seen within 12 weeks” and her symptoms as “Minor or moderate degrees
of persistent breast pain (no discrete palpable lesion)”, which they submit indicates that
the GP was not concerned about the First Complainant’s symptoms at that time.
The First Complainant says that in January 2018 she had attended the Breast Cancer
Family Risk Assessment Clinic and, in this regard, in her letter of complaint to the Provider
dated 7 April 2021, she submits that:
“I went to this clinic of my own volition just for a check. They told me by applying a
formula that I was slightly higher than normal risk and advised me to get an annual
mammogram. I did not receive any mammogram or investigation. Due to the
complications and daily stress of juggling a full time job with…young children, I did
not take the time to book an annual mammogram as I thought…there was no
urgent need … I have paid a heavy price for not taking the time to look after myself.
On the date of signing the proposal [for the Protection Insurance Policy on 6
March 2020], I had no recollection of this as I never went for any tests or
investigations and there was nothing wrong with me …
Again I feel I must emphasise, on signing the proposal form on 6th March 2020, I
had very minor breast discomfort which I was sure was period/menopause related
and the only reason it’s not on the form is that I thought there was nothing wrong
with me and didn’t even consider it for a second when answering the questions …
how could I hide something I was not aware of? …

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