Case Studies

Motor

  1. 1. Delay in notifying the Insurer: Vehicle stolen – Late notification of Theft claim for more than 4 weeks.
  2. 2. Delay in notifying the Insurer: Vehicle stolen - Insurer notified 4 months after incident.
  3. 3. Delay in notifying the Insurer: Vehicle stolen – Delay of 23 days in notifying the loss to the Insurer.
  4. 4. Delay in Lodging Police Report: Vehicle stolen – Police report lodged 9 days after the incident.
  5. 5. Exclusion: Owner lent his motorcar to a friend - failed to return the car - Met with an accident - Own Damage Claim rejected as motorcar allegedly used for Criminal Activity.
  6. 6. Exclusion: Motorcycle stolen – Rider was not in possession of a valid driving license.
  7. 7. Application of Average Clause: Vehicle underinsured - Application ‘Average clause’ policy in determining the cost of repair.
  8. 8. Failure to take reasonable precaution: Vehicle left unattended with engine running.
  9. 9. Failure to take reasonable precaution: Vehicle left unattended – Key in ignition switch – engine running.
  10. 10. Total Lost: ‘Total Loss’ Claim vs Insurer Cost of Repair
  11. 11. Tampered Chassis Number
  12. 12. Non –disclosure: Whether there was any non-disclosure by Insured in the absence of specific questions in the Proposal Form – whether there was a breach of para 5, Schedule 9 of the Financial Services Act 2013 by Insurer.

Life &General/ Family

  1. 1. Non-Disclosure: Critical Illness Benefit claim due to Breast Cancer – Failure to disclose history of ultrasound examination of the abdomen and pelvis   and bilateral mammogram in the Proposal Form.
  2. 2. Non-Disclosure: Death claim due to lung cancer – Undisclosed medical history of Hepatitis B in the Proposal Form.
  3. 3. Non-Disclosure: Death claim due to Subarachnoid Haemorrhage – Failure to disclose medical history of Hyperlipidaemia in the Proposal Form.
  4. 4. Non-Disclosure: Failure to disclose medical history of Syphilis 40 years ago in the Proposal Form.
  5. 5. Non-Disclosure: Failure to disclose medical history of skin rashes/allergic reaction in Proposal Form.
  6. 6. Total and Permanent Disability Claim: TPD claim due to Parkinson disease rejected by Insurer.
  7. 7. Total and Permanent Disability Claim: TPD claim due to Leg Amputation declined by Insurer.
  8. 8. Total and Permanent Disability Claim: TPD claim due to Eye related illness was refused by Insurer.
  9. 9. Delay in Notifying the Insurer: Claimant met with an accident - Claim filed not within stipulated time frame.
  10. 10. Personal Accidental: Death claim– Whether the cause of death was accidental or due to illness
  11. 11. Exclusion Cause: Driving without a valid driving license Whether it falls within the meaning of "illegal activities".
  12. 12. Exclusion Cause: Riding a motorcycle with an Expired License of more than 10 years.
  13. 13. Exclusion Cause:Preventive Medication: Is It Medically Necessary?
  14. 14. Exclusion Cause:Whether Riding with an Expired Licence is a Violation of the Law
  15. 15. Pre-Existing: Death benefit claim – dispute on pre-existing illness of Hypertension prior to Certificate inception - failure to support contention with medical evidence.
  16. 16. Investigatory Purposes: HSI claim due to ‘No Recurrent Brain AVM’ – Declined by Insurer as admissions solely for investigation purpose and not       Medically Necessary with no treatment rendered.
  17. 17. Terms and Conditions: Participant underwent CT coronary angiogram - Treatment administered as an outpatient - Insurer declined claim as treatment  does not comply which the certificate Coverage with requires admission.

General Non-Motor

  1. 1. Marine Cargo: Inland Transit Claim - Damage to cargo during unloading process from the conveyance.
  2. 2. Travel Insurance: Schedule flight missed – Unable to arrive on time to airport as train services were due to heavy snow – Declined by Insurers as circumstances of claim was beyond scope of policy coverage.
  3. 3. Burglary: Robbery at Outlet – Participant unable to comply to the new terms and condition of the Certificate as it was only made available to Participants after the loss had occurred.