Wiremu and Rachel planned to take a holiday to Japan in June 2019. Rachel purchased flights and the travel insurance in early January 2019. Wiremu had several medical conditions which he needed to disclose to the insurer, in particular, a number of heart conditions which he had suffered around 3 years earlier.

Rachel called the insurer to complete her medical assessment and thought she could save some time by also doing Wiremu’s medical assessment for him. The insurer said it was better for each person to do their own assessment, but Rachel said she knew her husband’s conditions best. During the call, Rachel disclosed that Wiremu had a heart murmur. When asked more specific questions about the condition, Rachel continued to refer to the murmur.  

Wiremu’s earlier heart condition unfortunately returned, and his doctors told him to cancel his holiday. Rachel made a claim on their insurance. 

The insurer then found that Wiremu’s condition was not a ‘heart murmur’ but a more serious underlying issue which was not disclosed to them.

As a result, the insurer declined Wiremu’s claim because Rachel had not represented Wiremu’s condition correctly and they would not have insured Wiremu’s condition if they knew what it was. Rachel was unhappy with the decision and complained to FSCL.

Dispute

Rachel said she had already told the insurer about Wiremu’s heart murmur. Rachel asked their GP to write to the insurer to explain that the term ‘heart murmur’ was wide and could mean a number of things. Rachel felt the insurer needed to ask better questions.

The insurer obtained a letter from Wiremu’s specialist. The specialist said that they had explained Wiremu’s condition to him and Wiremu said he would tell Rachel about it. The insurer said Rachel knew about Wiremu’s actual condition and that it was not just a murmur.

Review

We reviewed Wiremu’s complaint and considered that the specialist’s letter was clear and very detailed about what Wiremu was told. The specialist’s opinion showed that the heart murmur was a symptom of Wiremu’s more serious heart condition.

It was clear that Wiremu knew about his condition and should have disclosed it to the insurer.

The insured person’s duty of disclosure means that a person must disclose anything that a prudent insurer would consider material to decide whether or not to grant cover.  When Rachel called the insurer to disclose their health conditions, she innocently breached that duty by failing to disclose the seriousness of Wiremu’s condition.

Resolution

Although we accepted that Rachel’s non-disclosure was an innocent mistake, the law allowed the insurer to decline the claim because they were prevented from making an informed decision to grant cover. 

Rachel was not happy but accepted our explanation and discontinued her complaint.

Insights for consumers

When completing a medical assessment for travel or other insurance, it is a good idea for each person, who will be covered by the policy, to complete their own medical assessments.

It is important to disclose all health issues, even if they do not appear serious. Sometimes a small health issue may be a sign or symptom of a bigger issue that the insurer will wish to look into before agreeing to offer insurance cover. If you don’t disclose all material facts to the insurer, you may find the insurer will decline a claim or cancel the insurance altogether.