Not upheld: claim decline based on misrepresentation; service failure complaint against Zurich Insurance Company Ltd

Decision detail

Summary

Mr H and Miss P complained about Zurich's decline of a travel insurance claim following Mr H's emergency hospital treatment for severe back pain during a trip abroad. Zurich declined the claim, stating Mr H had failed to disclose medical consultations regarding back pain in his GP records from the two years prior to purchase, which constituted a misrepresentation of his medical history. The ombudsman found the insurance question was clear and unambiguous in requiring disclosure of any condition, even minor ones, seen by a doctor within two years, and that Mr H's multiple GP consultations regarding back pain fell within this scope. Although Mr H had not been formally diagnosed with a chronic spinal condition, the ombudsman upheld Zurich's application of CIDRA as a qualifying misrepresentation. The ombudsman also found Zurich's offered £200 compensation for service failures fair and reasonable.

The Ombudsman's reasoning

The ombudsman applied CIDRA, which requires consumers to take reasonable care not to misrepresent facts when taking out insurance. The question asked about any medical condition, even minor ones, seen by a doctor in the past two years. The ombudsman found the question was clear and unambiguous, and Mr H's GP consultations regarding back pain within that period constituted a failure to disclose. Although Mr H had not been diagnosed with a chronic spinal condition and symptoms were temporary, the question did not require an ongoing diagnosis—merely consultation about a condition. Zurich demonstrated it would not have offered the policy had the question been answered affirmatively, making this a qualifying misrepresentation. The ombudsman found Zurich's actions compliant with CIDRA and the £200 compensation for service failures fair and reasonable.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website