Not upheld: policy avoidance for misrepresentation; failure to disclose material medical conditions complaint against Western Provident Association Limited (WPA)

Decision detail

Summary

Mr S and Mrs S complained that WPA unfairly avoided their private medical insurance policy and refused a cancer treatment claim. Mr S had applied to switch policies in July 2025, declaring only aplastic anaemia and CMV colitis. WPA later discovered Mr S had failed to disclose Crohn's disease (despite gastroenterologist letters indicating this diagnosis), a skin condition requiring dermatology referral, and a prior serious illness. The ombudsman found Mr S failed to take reasonable care in his disclosures and that WPA would not have offered the policy had it known the full medical history. Under CIDRA, WPA was entitled to avoid the policy and refuse claims while refunding premiums, so 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 ombudsman found that Mr S failed to take reasonable care by not declaring Crohn's disease (despite clear gastroenterologist letters indicating this diagnosis), a skin condition requiring dermatology referral and medication, and a prior serious illness (sepsis and pneumonia). The ombudsman found these were misrepresentations a reasonable consumer would have disclosed. The ombudsman accepted WPA's evidence that it would not have offered the policy had it known the full medical history, making these qualifying misrepresentations. Under CIDRA, for careless misrepresentation, the insurer can avoid the contract and refuse claims while refunding premiums, which WPA did.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website