Upheld: unfair retrospective exclusion application; alleged misrepresentation on medical insurance policy complaint against CIGNA Life Insurance Company of Europe SA-NV

Decision detail

Summary

Mrs A complained that CIGNA unfairly retrospectively added an exclusion to her international private medical insurance policy and declined her claim for foot surgery. CIGNA argued Mrs A should have declared the foot condition when taking out the policy in August 2021, relying on the surgeon's initial report stating the deformity started one year prior. However, the surgeon later clarified that the underlying condition can exist without symptoms and likely began only 4-5 months before pain onset, meaning Mrs A would not have been aware of it at policy inception. The ombudsman upheld the complaint, finding Mrs A did not make a misrepresentation as she was not aware of any issue when applying for the policy, and directed CIGNA to remove the exclusion, pay the claim with interest, and restore the policy.

The Ombudsman's reasoning

The ombudsman applied the Consumer Insurance (Disclosures and Representations) Act 2012 (CIDRA), which requires consumers to take reasonable care not to make a misrepresentation. The key question on the application asked for 'known or suspected issues'. The ombudsman found that while the surgeon's initial report suggested the deformity started one year prior, the surgeon's later correspondence provided a reasonable explanation: the underlying condition can exist without symptoms, and the deformity likely began 4-5 months before pain onset, meaning Mrs A would not have been aware of it in August 2021. Combined with Mrs A's consistent testimony that she first became aware of the problem in February 2022, the ombudsman concluded Mrs A did not make a misrepresentation as she was not aware of any issue at the time of policy inception.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website