Not upheld: misrepresentation on insurance application and claim denial complaint against Western Provident Association Limited

Decision detail

Summary

Miss J complained that WPA unfairly added an endometriosis exclusion to her private medical insurance policy and refused to pay her claim for a urinary and gynaecological scan. WPA had discovered through Miss J's medical records that she had failed to disclose recent medical history including GP visits for endometriosis concerns and a gynaecology referral, which should have been declared when applying for the policy in September 2023. The ombudsman found that Miss J failed to take reasonable care not to misrepresent her medical history under CIDRA, and that WPA's questions were clear and reasonable. As WPA demonstrated it would have offered the policy with an exclusion had correct information been provided, the misrepresentation was qualifying, and WPA was entitled to apply the exclusion and decline the claim. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman applied The Consumer Insurance (Disclosure and Representations) Act 2012 (CIDRA), which requires consumers to take reasonable care not to make misrepresentations. The questions asked by WPA were clear and based on Miss J's medical records, it was reasonable to expect 'yes' answers. Although Miss J's failure to recall was understandable, CIDRA requires reasonable care regardless. WPA demonstrated the misrepresentation was qualifying because it would have offered different terms (an exclusion) with correct information. As the misrepresentation was careless rather than deliberate, WPA was entitled to add an exclusion and assess claims accordingly. The scan fell within the exclusion as it related to pre-existing menstrual and urological symptoms that should have been declared.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website