Not upheld: claim rejection based on alleged misrepresentation; non-disclosure of material medical information complaint against Vitality Life Limited

Decision detail

Summary

Miss D complained that Vitality Life Limited unfairly rejected her serious illness claim for breast cancer, alleging she had made a careless misrepresentation by failing to disclose a breast fibroadenoma diagnosed in 2021 and abnormal cervical smear results from 2022 when applying for personal protection cover in April 2023. Vitality concluded Miss D should have disclosed these conditions when answering specific health questions and retrospectively applied exclusions for breast and cervical cancer to the policy. The ombudsman found the application questions were clear and specific, the medical events were sufficiently recent to be reasonably memorable, and Vitality had provided Miss D with documentation to verify the application information. The ombudsman was satisfied Vitality demonstrated a qualifying misrepresentation under The Consumer Insurance (Disclosure and Representations) Act 2012 and that it would have applied the exclusions had accurate information been provided. Therefore, the complaint was not upheld and Vitality acted fairly in rejecting 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 make misrepresentations. The ombudsman found the application questions were clear and specific enough to prompt Miss D to disclose her medical history. The fibroadenoma (14 months before application) and abnormal smear (5 months before application) were sufficiently recent that Miss D should have remembered them. Although Miss D may not have known the technical term 'fibroadenoma', she knew she had a breast lump and should have answered 'yes' to the question about lumps, growths or cysts. The ombudsman was satisfied Vitality demonstrated a qualifying misrepresentation under CIDRA and that it would have applied exclusions for breast and cervical cancer had it known the true medical history. Under CIDRA, for careless misrepresentation, an insurer may retrospectively apply exclusions and rely on them when assessing claims. Therefore, Vitality acted fairly in turning down the breast cancer claim.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website