Non disclosure complaints
Sometimes insurers might decline to pay your insurance claim because they say you didn’t tell them something about your health or lifestyle when you took the policy out- this is referred to as non-disclosure, which is a type of ‘misrepresentation’.
If your insurer declines to pay your claim for this reason, they should put the reasons why they have come to this decision in writing. This letter would usually tell you the questions they asked you when you took the policy out, and what medical information they have become aware of, that would suggest you didn’t answer this question accurately. It’s important to be aware that it is your duty, as a consumer, to answer any questions the insurer, or your representative, asks you truthfully and honestly.
In essence- you need to take ‘reasonable care’ to make sure that you do not ‘misrepresent’ the facts of your health and lifestyle.There is lots of legislation that surrounds non-disclosure and misrepresentation- we will talk you through the key elements to be aware of.
The Consumer Insurance (Disclosure & Representations) Act
sets out the actions an insurer can take if they believe you didn’t tell them something about your health or lifestyle, that they think you should have done, when you took the policy out. Firstly, the insurer needs to consider the ‘type’ of misrepresentation, they are classing your mistake as. This could be ‘Careless’, ‘Deliberate’ or ‘Reckless’:
Deliberate/Reckless misrepresentation is defined by The Consumer Insurance (Disclosure & Representations) Act as: ‘The insured person knew that it was untrue or misleading, or did not care whether or not it was untrue or misleading, and knew that the matter to which the misrepresentation related was relevant to the insurer, or did not care whether or not it was relevant to the insurer.’
’In terms of ‘Careless’ misrepresentation
The Consumer Insurance (Disclosure & Representations) Act says: ‘A qualifying misrepresentation is careless if it is not deliberate or reckless.’
The action an insurer can take depends on the ‘type’ of misrepresentation they are defining your mistake as being:
Deliberate/Reckless
The insurer can ‘avoid’ the policy. This means the insurer can cancel the policy from when it started and doesn’t need to refund the premiums you have paid.
Careless
The insurer has to look at what action they would have taken if you’d given the ‘correct’ answer at the time you took the policy out.
If your error is seen by the insurer as being ‘Careless’, the action they take will depend on whether they would have offered you the insurance policy, or would have done so on different terms, had you answered the question accurately when you first took the policy out.
Here are the typical outcomes in instances of ‘Careless’ misrepresentation:
The ‘correct’ answer would not have impacted the policy in any way
The insurer will continue to assess the claim as normal and if your claim meets the terms of the policy, they will pay the claim in full
The insurer would not have offered cover at all
The insurer will cancel the policy as though it never existed and will refund all of the monthly premiums you have paid.
The insurer would have charged a higher monthly premium
The insurer will continue to assess the claim as normal and if your claim meets the terms of the policy, they will pay a ‘proportionate’ amount.
This means the insurer will look at the amount they would have charged, versus what you have actually paid and will reduce the amount they pay out accordingly e.g. if you should have been paying £50 a month for the policy, but have actually only paid £25 per month, the insurer will reduce the amount they pay out on your claim by 50%
The insurer would have applied an ‘exclusion’ to the policy- meaning that they would have not covered certain medical conditions
The insurer will continue to assess the claim as normal and if you are claiming for any medical condition that is not ‘excluded’ they will pay your claim.
If your claim is related to the excluded medical condition, they may refuse to pay your claim.
How can Appeal Avenue help you?
Here at Appeal Avenue we have many years of experience in reviewing declined insurance claims, as a result, we have helped to overturn many claims that have been declined due to non-disclosure misrepresentation.
We will review your letter of decline from your insurer and will consider:
What question is the insurer saying you didn’t answer correctly?
We will consider how clear the question was and whether or not a ‘reasonable’ person would have answered differently.
What ‘type’ of non-disclosure is the insurer defining your mistake as?
If the insurer is saying that the mistake is deliberate or reckless, we will use our experience and understanding of your situation to assess whether or not you have grounds to appeal this.
If the insurer says they would not have offered you cover, would have applied an exclusion or is paying a ‘proportionate’ amount, is this fair
We will use our experience of claims outcomes to assess whether or not you have grounds to appeal.
If you would like our support with making a complaint or appeal, make an appointment with us today and we will chat through what has happened and what your options are – take a look at the fees section of our website for an idea of the costs involved.