Many life or medical insurance claims are declined for alleged non-disclosure – often of an unrelated medical symptom or condition. Sadly this tactic is generally used against widows and the bereaved families of the policyholder. The dispute typically arises at the worst time therefore, when vulnerability is high.
We have found that very often the medical history on application forms for insurance cover are completed from the applicants own remembrance of his / her medical history but, perhaps unsurprisingly, once a claim is actually made the insurer has a peculiar insistence on going through the clinical history word by word, letter by letter line by line. These “small print” denials are stock in trade for Health Insurance.
Insurers will attempt to decline or reduce perfectly reasonable claims often due to allegations on non-disclosure or other breaches of policy conditions or exclusions. Often these technical arguments are either unfounded or misinterpreted deliberately by insurers. Do not be bullied.
Disclosure clauses are problematic for insurers, they need to look carefully at the motivations that lay underneath the alleged disclosure issue. They must ask themselves whether the non disclosure was deliberate and intended to deceive the insurer about the risks in the policy. These are what used to be referred to as “material non disclosures” but are probably better termed “deliberately deceptive”. They must also ask, was the disclosure innocent? In other words, was the disclosure not made because the applicant wanted to deceive but genuinely did not know (usually because no doctor has ever told them, though it may be in the clinical notes). There may also be issues of recklessness in disclosure, ie you put down “never had high blood pressure” but knowing that the symptoms for high blood pressure are present but you deliberately haven’t been to the doctors to have it recorded. There may also be inadvertent non disclosure where the applicant simply misses the point on the application form but not out of any intention to deceive.
If there is a innocent non disclosure the premiums may be returnable and you may get some degree of payment out. It may also be that the non disclosure actually would have had no impact on the risk on the policy. In such a situation even if there as a deliberate lie, it could still mean the policy has to pay out.
If you have a critical illness claim or fatal accident claim regardless of whether this is a refusal on grounds of innocent, deliberate, or inadvertent non-disclosure, or other policy term your going to need a lawyer to figure it out. There is of course the possibility of going straight to the ombudsman but if you do, there is also the chance that your action could pass limitation whilst the process is ongoing. This could mean that your claim will be barred from ever going to court. Ultimately if you approach a insurance lawyer first, the case can be protected from limitation.
They will fully consider your individual case and advise you whether you have a potential claim. This often involves careful consideration of your Policy and medical history. Surprisingly one in five life and critical illness policies are rejected by Insurance Companies but less than 1 in 1000 are challenged