Case 5: Hospitalisation Claim – Failure to disclose medical history of skin rashes/allergic reaction in Proposal Form

Background

The assured’s medical claim was rejected on the ground that the assured had failed to disclose her medical condition, i.e. treatment for skin rashes/allergic reaction, in the proposal form dated 29 October 2015.

The insurer’s decision was based on the medical questionnaire completed by a doctor from a clinic which reported that:-

  1. the assured had history of treatment for skin rashes/allergic reaction; and
  1. the attending doctor had first treated the assured in 2010.

Investigation and Findings

The insurer contended that the assured should have disclosed his medical condition, i.e. treatment for skin rashes/allergic reaction in the following questions:-

“6. Have you ever suffered from, or been told that you are suffering or have suffered from, or received any treatment for:-

(k)   Backache, slipped disc, spondylosis, arthritis,rheumatoid arthritis, systemic lupus erythematosus (SLE), osteoporosis, gout, psoriasis, chronic skin disease or other disease or disorder of the immune system, connective tissue, spine, muscle, bone or joint?

11.       Are there any other circumstances not already disclosed elsewhere in this proposal form that would render an assurance on your life more than usually hazardous? If you are in doubt on whether certain circumstances are more than usually hazardous, these circumstances should be disclosed.””

Nevertheless, it was observed by the Case Manager that:-

  1. there was no specific question in the Proposal Form which requires the assured to disclose her skin rashes/allergic reaction;
  1. the question in the said form requires the assured to disclose chronic skin disease;
  1. in the proposal forms of other Insurance companies, they have specific question which includes skin disease; and
  1. based on Paragraph 5 of the Financial Services Act 2013, Pre-contractual duty of disclosure for consumer insurance contract and Bank Negara Malaysia Guidelines on Medical and Health Insurance Business (BNM/RH/GL/003-20), it is the duty of the insurers to frame questions in the proposal form clearly and accurately to solicit information.

Based on the assessment above, the Case Manager was of the view that the complainant’s claim warrants a review.

Settlement

The insurer concurred with the Case Manager’s assessment and settled the claim