Haoyu was first treated for a gastrointestinal tract issue in November 2017. He made a claim to his health insurer when he had a gastroscopy in March 2018. In April 2018, Haoyu was diagnosed with a condition that required surveillance gastroscopies, with one scheduled for two years’ time.
Haoyu met with an insurance adviser in December 2018 to discuss changing his health insurer. The adviser suggested that Haoyu change insurer, which he did in February 2019.
In 2020, Haoyu contacted the adviser to make a claim for the costs of his next scheduled gastroscopy. The new insurer declined his claim. The insurer had obtained Haoyu’s medical notes and applied exclusions relating to gastrointestinal issues.
Haoyu believed that he had disclosed all necessary information to his adviser and that the adviser had erred by not including this information in the insurance application form. The adviser disagreed, so Haoyu complained to FSCL.
Haoyu said that he had told the adviser about his condition and gastroscopy investigation history. Haoyu did not speak much English, and he and the adviser spoke to each other in Mandarin. Haoyu said that he trusted that what the adviser wrote in English on the application form correctly reflected what he had said in Mandarin. Haoyu believed that the adviser should have reviewed his medical file to determine what needed to be disclosed on the form. Further, he said that the adviser said that Haoyu did not need to fully disclose his gastrointestinal history to the insurer “since it was fine now”.
The advising company was of the view that there were no shortcomings in the adviser’s process. They said that Haoyu had not fully disclosed the seriousness of his condition.
We had to decide which version of events was more likely to be correct – either Haoyu did not fully disclose his gastrointestinal tract issues to the adviser, or he disclosed the issues, but the adviser did not fully disclose the issues to the insurer. On balance, we concluded that it was more likely than not that Haoyu did not fully disclose his gastrointestinal issues to the adviser. We could not know for certain what had happened because there was no recording of what was said. Further, the adviser had left the advising company so it was unlikely we would be able to get him to speak to us. It was also unlikely that the adviser would remember the conversation in sufficient detail.
We balanced the evidence that was available to us, and reached our decision based on the following:
- Evidence suggested that the adviser did not know about Haoyu’s most recent (and arguably most serious) diagnosis of gastrointestinal issues because in Haoyu’s complaint to FSCL he did not say that he had disclosed his most recent diagnosis to the adviser. Further, in written communication in July 2020 the adviser told Haoyu that he did not know of the recent diagnosis until the insurer requested doctors’ notes, and Haoyu did not challenge the adviser on this matter.
- The risk analysis document was the closest thing we had to a file note. The document mentioned vague gastrointestinal symptoms and implied that only a one-off treatment was required. Neither the risk analysis document nor the statement of advice mentioned gastroscopies or Haoyu’s diagnoses. We noted that we could not regard the risk analysis document as a complete record of everything that was discussed, particularly due to the discussion being in Mandarin and the document in English.
- Also, the adviser’s words “since it was fine now” implied that the adviser was under the impression that there was no ongoing issue with Haoyu’s stomach. This suggested that the adviser did not have enough information to know the extent of Haoyu’s gastrointestinal issues or that they were monitored on an ongoing basis.
- We also considered it seemed inherently unlikely that the adviser would have said that Haoyu did not need to disclose his gastrointestinal diagnosis and the need for future gastroscopies, if the adviser knew about them. If this were the case, the adviser likely would not have written “stomach ache” on the application form. It was more likely that the adviser did not realise the nature and extent of the stomach problem. The fact that the conversation was in Mandarin and the disclosure information was recorded in English did not change this.
- Haoyu received a copy of the application form before it was submitted with the instruction to check that it was correct. Haoyu had adequate opportunity to have someone proficient in both English and Mandarin to review the form and check that his full medical history had been disclosed. However, we placed less weight on this than usual due to Haoyu not being proficient in English at the time, so he may have been more reliant on what the adviser said to him in Mandarin.
- Asking a client to obtain their medical file is not a step an adviser will take as a matter of course. The adviser may have suggested that Haoyu obtain his file if more detail was required, Haoyu’s recollection of his medical history was poor, or if Haoyu’s medical history was particularly complex. None of these scenarios would have been triggered by the adviser’s knowledge of a minor stomach problem.
- Haoyu believed that the adviser should have been aware that he had previously claimed under his original health insurance for the gastroscopy cost. However, there was no positive requirement on advisers to check claim histories with clients’ previous insurers when applying for cover with a new insurer.
We suggested that Haoyu discontinue his complaint. We were not suggesting that Haoyu was being untruthful in making his complaint, but rather that the weight of the evidence fell on the side of the adviser not being aware of the full extent of Haoyu’s gastrointestinal issues.
Haoyu did not agree with our preliminary decision, but he did not provide any further compelling evidence that changed our view. We closed our complaint file.
Insights for consumers
Consumers should take care to ensure that all medical information is disclosed to their adviser when applying for health and life insurance. It is important to review the information that the adviser records to ensure that it is correct and complete so that you receive the most suitable cover. If a consumer does not disclose all health conditions and previous tests carried out, an insurer may later decline a claim on the ground of non-disclosure of a pre-existing medical condition.