Greg spoke with an insurance adviser about acquiring health insurance in 2020. Greg said he mentioned his recent eye procedure to his adviser several times, who filled the application form out for him. The adviser provided one insurer option to Greg, which Greg accepted.
Greg later submitted a claim to the insurer for an eye surgery. The insurer declined his claim due to the previous eye procedure not being disclosed on his application form. Greg complained to FSCL that the adviser had failed to adequately disclose his medical history.
Greg said that the adviser’s error of not including the previous eye procedure on his application form had caused the health insurance to be of no use to him. He said that he had paid the premiums but received no benefit because he would not be able to claim for eye-related medical procedures in future. Greg wanted the adviser to compensate him for the premiums he had paid ($2,250).
The adviser said she could not recall Greg mentioning the eye surgery. She did not have any notes from their conversation.
We sent the adviser a summary of Greg’s complaint. The adviser decided to settle the complaint early by refunding Greg’s premiums of $2,250 rather than continuing with the FSCL investigation process. This may have been due to the adviser having incomplete records.
The adviser refunded Greg the annual premiums, which resolved his complaint.
Insights for participants
Insurance advisers should take care to disclose everything a client tells them about prior medical conditions, ensure they explain the duty of disclosure to clients, and ensure clients have adequate opportunity to disclose their prior history. This case was also a good example of the benefits of an early settlement – it not only leads to greater client satisfaction, but also saves time and money in the complaints process.