Critical & Serious Illness Decision Reference 2022-0324

• Case Outcome: Rejected
• Subject Matter: Critical & Serious Illness
• Reference: 2022-0324
• Date: 26 September 2022
• Finantial Sector: Insurance
• Conducts Complained Of: Claim handling delays or issues,Delayed or inadequate communication, Lapse/cancellation of policy, Rejection of claim, Rejection of claim - fibromyalgia

Decision Ref:

2022-0324

Sector:

Insurance

Product / Service:

Critical & Serious Illness

Conduct(s) complained of:

Claim handling delays or issues

Delayed or inadequate communication

Lapse/cancellation of policy

Rejection of claim - fibromyalgia

Rejection of claim

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The Complainants incepted a Specified Illness Insurance Policy with the Provider on 15 July

2016, which provided each of them with stand-alone specified illness benefit in the amount

of €100,000.00 (one hundred thousand Euro) for a term of 20 years. The Complainants

initially applied for this policy through a Provider Insurance and Investments Manager on 31

March 2016. The Complainants, as part of the same application process, also applied for a

Life Assurance Policy with the Provider on the same date, which was incepted on 6 July

2016.

This complaint concerns the Provider’s decision to decline the Complainants’ specified

illness claim made in June 2019 (and to void the Specified Illness Policy due to the non-

disclosure of material facts) as well as its associated decision to reduce the cover provided

by the Life Assurance Policy due to the same suggested non-disclosures.

The Complainants’ Case

The Complainants submitted a Specified Illness Claim Form to the Provider on 6 August

2019 in respect of the cardiothoracic open-heart surgery that the Second Complainant

underwent in July 2019 to repair a partial anomalous pulmonary venous drainage. The

Second Complainant advises that symptoms of this condition, which her Cardiac Surgeon

described to her as “an extremely rare congenital cardiac defect”, first commenced during

2018 with the diagnosis made in June 2019. The Complainants say that following this

diagnosis, “corrective surgery was held within weeks in July [2019]”.

- 2 -

/Cont’d…

The Second Complainant wrote to the Provider on 9 October 2019 to query its delay in

processing the claim, as follows:

“You have had a full concise reports from my Cardiac Consultant and also my GP.

Having had major open heart surgery - clearly covered in your terms and condition of

our policy - can you explain the reason for the length of the enquiry and repeated

requests for information. We were originally told on return of medical reports it

would take 5-10 days to process.

I have been with the same GP for 8 years which is more than the duration of our policy

with you, and I would like to know why you have now requested further information

from my GP, having already had a full report.

Having spent 2 days in Intensive care, 3 days in High Dependency Unit and a total of

11 days post op in hospital, I am now 10 weeks into a very slow 12 week recovery,

and will require a cardiac recovery program for a further 8 weeks.

The delay in processing this claim which is in very clear compliance with the terms of

our policy is very disappointing and causing distress in my recovery period. We have

been a long-term customer of [the Provider] … and this customer service level we feel

is not appropriate in particular considering the serious and unequivocal nature of my

condition and surgery”.

The Provider replied to the Complainants by letter dated 15 October 2019 advising that it

had written to the Second Complainant’s GP on 7 October 2019, seeking further information

regarding certain medical conditions and investigations (recorded in the medical file her GP

had previously sent to it on 28 August 2019) which pre-dated the commencement of the

policy, and which had not been disclosed when applying for cover.

Following its claims assessment, the Provider wrote to the Complainants on 14 January 2020

to advise that it was declining the claim and voiding the Specified Illness Policy because the

Second Complainant had failed to disclose material facts relating to her medical history

when applying for the cover.

It said that if it had been made aware of these details at the time, it would not have been

in a position to offer her any specified illness cover. The Provider then wrote to the

Complainants on 28 January 2020 to advise that it had refunded to them the sum of

€6,400.98 (six thousand four hundred Euro and ninety-eight Cent), this representing a

refund of all premiums paid into the policy, since its inception in 2016.

The Provider also advised in its letter of 28 January 2020 that if it had been made aware of

the Second Complainant’s full medical history at the time the Complainants had applied for

their Life Assurance Policy, which was at the same time they had applied for their Specified

Illness Policy, it would then have been necessary for the Provider to have applied a loading

to that policy.