Death Claim - Non-Disclosure

Background

The assured passed away due to advance lung cancer and the assured’s wife (complainant) submitted a claim under the death benefit. However, the complainant’s claim was rejected on the ground that the assured had failed to disclose his medical condition, i.e. Hepatitis B, which was not disclosed in the proposal form dated 16 August 2010.

The insurer’s decision was based on the medical questionnaire completed by a doctor from the hospital which reported that the assured had history of Hepatitis B detected in 2009. It was further reported that the attending doctor had first treated the assured in 2011.

 

Investigation and Findings

The insurer contended that the assured should have disclosed his medical condition, i.e. Hepatitis B in the following questions:-

12(c) Have you ever consulted or been treated for or had any indication of any other disorder of the stomach, intestines, liver, gallbladder, pancreas or digestive system?

12(i) Have you ever consulted or been treated for or had any indication of any other illness, disorder not mentioned above?

 

Nevertheless, it was observed by the Case Manager that there was no specific question, which requires the assured to disclose his Hepatitis B. It was also observed that in the proposal forms of other Insurance companies, they have specific question which includes hepatitis condition. The Case Manager stressed that it is the duty of the insurers to frame questions in the proposal form clearly and accurately. The assured is entitled to take the questions posed by an insurer in a proposal form on their face value.

In addition to the above issue, the Case Manager also highlighted that there was no evidence proffered to show that the assured was diagnosed and informed of his medical condition, i.e. Hepatitis B.

A decision to decline a claim based on non-disclosure of a pre-existing condition must be based on proper medical record or documentary evidence as a result of medical test or examination. There must be clear medical evidence that the assured had been diagnosed as suffering from particular illness prior to completing the application form and the statement must be supported by factual evidence, in particular the date of diagnosis, the name of the doctor who made the diagnosis and the treatment/medication prescribed.

 

In this present case, based on the medical questionnaire completed by a doctor from the hospital it was noted that:-

  1. The assured had first consulted the doctor on 3 January 2011;
  2. There was no information on the details of the doctor who diagnosed the assured in 2009; and
  3. No evidence whether the diagnosis in 2009 was informed to the assured.

Based on the observation above, the Case Manager opined that the complainant’s claim warrants a review.

 

Settlement

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