Not upheld: claim decline - non-disclosure of medical information / misrepresentation complaint against The Royal London Mutual Insurance Society Limited

Decision detail

Summary

Ms A, as trustee of the G Trust, complained that Royal London unfairly declined a life insurance claim following Mr G's death, alleging he had not accurately disclosed his medical history. Mr G had answered 'no' to questions about specialist referrals when applying in November 2016, but was referred to a Parkinson's clinic in December 2016 after a GP appointment. He did not disclose this referral on the confirmation form sent in January 2017, despite being prompted to report any changes. The ombudsman found that Mr G was most likely aware of the referral based on the GP referral letter and consultation notes, and that his failure to disclose it constituted a deliberate or reckless qualifying misrepresentation under CIDRA. Since Royal London provided evidence they would not have offered the policy had they known of the referral, the ombudsman upheld Royal London's decision to decline the claim.

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 misrepresent information. The ombudsman found that Mr G was most likely aware of the neurological referral based on the GP referral letter explicitly discussing possible Parkinson's disease and the consultation notes documenting discussion with Mr G. Since the referral occurred before Mr G returned the confirmation form (which prompted disclosure of changes), Mr G should reasonably have disclosed it. The ombudsman was satisfied this was a qualifying misrepresentation because Royal London provided evidence they would not have offered the policy had they known of the referral. Given the proximity of the referral to the application process and Mr G's profession, the ombudsman concluded the misrepresentation was deliberate or reckless rather than merely careless, entitling Royal London to decline the claim under CIDRA.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website