Not upheld: Home insurance claim disputes complaint against Cigna Europe Insurance Company SA

Decision detail

Summary

Mr P complained that Cigna unfairly declined his claim for hip arthroplasty surgery and applied an exclusion to his private medical insurance policy. Mr P had hernia surgery in August 2020 and experienced continuing pain from September 2021. When he took out a Cigna policy in December 2021, he disclosed the hernia surgery but not the continuing pain, and answered that he was fully recovered. In May 2022, he was diagnosed with coxarthrosis and sought approval for surgery, which Cigna declined. The ombudsman found that Mr P failed to take reasonable care not to make a misrepresentation by not disclosing his pain symptoms, and that this constituted a qualifying misrepresentation under CIDRA. Since Cigna demonstrated it would have applied an exclusion for right hip disease had it known the true position, the ombudsman upheld Cigna's decision to decline the claim and did not uphold Mr P's complaint.

The Ombudsman's reasoning

The ombudsman found that Mr P failed to take reasonable care not to make a misrepresentation when taking out the policy. When asked if he had any illness, condition or symptom not already mentioned, Mr P answered 'no' despite having pain. When asked if he was fully recovered from his hernia with no recurrence for over 12 months, Mr P answered 'yes' despite having continuing numbness and pain. Although Mr P believed his pain was nerve damage that would diminish, this did not change the fact that he should have disclosed it. Cigna demonstrated that if it had known the true position, it would have offered cover on different terms with an exclusion for right hip disease or disorder, making this a qualifying misrepresentation under CIDRA. The medical report provided by Mr P lacked sufficient detailed explanation or evidence to support the assertion that the hernia-related pain was unrelated to the osteoarthritis diagnosis.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website