Employers Liability Decision Reference 2022-0223

Case OutcomeRejected
Date01 July 2022
Subject MatterEmployers Liability
Finantial SectorInsurance
Conducts Complained OfLapse/cancellation of policy,Rejection of claim - non-disclosure
Decision Ref:
Product / Service:
Employers Liability
Conduct(s) complained of:
Lapse/cancellation of policy
Rejection of claim - non-disclosure
This complaint arises from an Executive Income Protection Plan incepted with the Provider
on 6 March 2012. The Complainant was not the policyholder, but she makes this complaint
in her capacity as an actual or potential beneficiary of a “long-term financial service” within
the meaning of the Financial Services and Pensions Ombudsman Act 2017. The Policyholder
was the Complainant’s employer. The Complainant, as the life assured, completed the
application for cover through an Insurance Intermediary (‘the broker’). The Provider was the
Insurer, responsible for underwriting the applications for cover and assessing claims.
This complaint concerns the Provider’s decision in July 2018 to decline the Complainant’s
income protection claim and to cancel the policy from inception, on the basis that she had
failed to disclose her full medical history when applying for the cover.
The Complainant’s Case
The Complainant completed and submitted an income protection Claim Form to the
Provider on 28 May 2018, wherein she advised that she had not attended worked since 22
May 2018 due to “Stress, lack of sleep, stress, anxiety”.
Following its claim assessment, the Provider wrote to the Complainant on 23 July 2018 to
advise that she had failed to disclose her full medical history when applying for cover and
that its underwriters had confirmed that if it had been aware of such information, when
considering her policy application, it would not have been in a position to offer terms of
cover. As a result, the Provider declined the Complainant’s income protection claim and
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voided the Executive Income Protection Plan from inception, and it refunded to the
Policyholder all premiums paid since the commencement of the policy.
The Complainant wrote to the Provider on 13 September 2018 to appeal its decision to
decline her income protection claim and void the policy from inception, as follows:
“ … I feel my initial application form was rushed and not given the due time needed,
and my Nurse Medical was loosely carried out and the Nurse made some grave errors
in completing the application form by giving incorrect answers. I am disputing the
way the Nurse Medical was carried out, for example, “Have all “Yes” questions been
fully answered = YES”. This should have been a “No” answer. Of course the Nurse
Medical would not have expected me to remember/know all the dates/years of the
scans/x-ray’s etc, but the Nurse should have requested this information from my GP
especially as I answered “yes” which covered all parts of the question, not just Bloods.
In my original application I consented for a PMA [(GP Report)] to be completed but
this was never done. I have been blessed with good health all of my life, I can
occasionally be forgetful when I am very busy (managing a [place of employment]
with 50 staff with a €3 million turnover), as can be verified in my Medical Notes where
I complained of worrying about poor memory over the years. There was never a
question on either the application form or the nurse medical to ask me about poor
memory. I did attend for an MRI due to my concerns regarding my memory loss and
this came back clear. My GP advised me at the time it was nothing more than a busy
mind trying to retain everything.
I think that it is unreasonable and unfair that a PMA was not done as I gave full
permission for this on my application form. It was never explained to me at the time
of the nurse medical that any omissions would make this application invalid, and as
per the Nurse Medical I was never encouraged to pursue any additional medical
advice and more importantly when the nurse medical was finished I was not given
the opportunity by the nurse to scroll back and review the questions from the start, I
had answered before I signed, as these were all on the nurses laptop. If that had been
done, mistakes would have been spotted then in 2012 and corrected immediately.
Receiving this information in July 2018 was far too late to review and correct. I was
simply asked to sign the form by the nurse. I feel there was/is a duty of care by the
Nurse to go through what I had completed.
To the best of my knowledge for all current Income Protection Applications, the client
is now afforded the opportunity to review all questions answered before the
application is fully submitted to the Life Company, therein removing the margin for
I would plead with you not to reject my claim/application. I have worked from
inception date of the policy in 2012 to the current time 2018 without every (sic) have
(sic) any claim on my policy. I need the assurance going forward that I am protected
for the remainder of my working life as it is my full intention to work on for another
number of years”.
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The Complainant enclosed additional correspondence to the Provider in support of her
In that regard, in the enclosed Report dated 23 July 2018, the Complainant’s GP stated that:
[The Complainant] aged (sic) is 60yrs. She finds herself currently in a very stressful
situation and has severe difficulty with anxiety as a direct result. She is unable to
sleep and is anxious, emotional and distressed. She is suffering panic attacks and is
unable to concentrate. She never felt like this in the past. I have advised against work
as her job is extremely stressful. I have commenced her on medication and advised
counselling. This is completely different to any situation she ever encountered in the
I wish to clarify her past medical history. [The Complainant] attended me in 2004 with
a bereavement reaction of tiredness and low mood which I documented in her notes
as such. She needed to work as she was in a busy job and indeed she did and was fit
to do so. I treated her for a very short time (my notes show a period of 5 weeks only)
with a low dose SSRI [selective serotonin reuptake inhibitor] to help her to get on
with her busy life. She has been a regular patient since that time over 14 years and
did not require any further treatment for mood. [The Complainant] had not
considered this of any consequence.
In 2012 she embarked on an insurance policy. There was no PMA requested and if
there had been it would have included her brief sadness reaction in 2004. I wonder
why this was not requested. I also insist that she dis (sic) not suffer any mental health
issues for over 16 years.
Mild depression is not anxiety and [the Complainant] never suffered anxiety in the
past. I concur strongly with her assertion that she did not suffer from any mental
health issues at any time in the past but a natural response to a personal loss in the
dim distant past that bears no relationship to her current anxiety disorder. Further
should I have been given the opportunity to provide a PMA report the current
situation would not have arisen.
In the enclosed Report dated 9 August 2018, the Complainant’s treating Occupational
Physician stated that:
[The Complainant] has asked me to write this report in support for her appeal
against [the Provider’s] decision to decline/terminate her claim. In addition to her
own history she has provided me with documents from [the Provider] outlining its
reasons for terminating her claim.
My first impression on reading your documentation, is that some clerk was asked to
find every possible thing in the doctors PMA that could suggest withholding of
material information, and provided a comprehensive list, all of which are not
factually correct.

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