What happens if an insurer rejects a claim?
In the event of a dispute on an insurance claim, it can be referred to the Financial Ombudsman who will consider the facts before judging whether the insurer needs to make the payment or not.
They will start by looking at why the insurer believes that the consumer misrepresented their situation and how important it was in their decision to offer the policy. In other words, would they have taken on the policy, knowing what they now know?
They’ll look at whether the insurer met its obligations and asked all the right questions.
Finally and most importantly from your point of view, they will then look at whether the consumer took what’s known as “reasonable care”. This means that the Ombudsman will recognise the difference between a consumer genuinely not knowing of an illness for example, and a consumer who knew about an illness and lied to the insurer about this when taking out a policy.
If they find that the consumer took all reasonable care when answering the questions they are likely to force the insurer to pay out on the policy.
If they decide that the consumer did not take reasonable care when answering, they may look to see if a ‘proportionate’ response is required. This means whether some form of compromise is appropriate. This would include looking at how much was paid in total to the insurer, how long the premiums were paid for and so on.
Finally, if they find that the consumer deliberately or recklessly misled the insurer they are likely to allow the insurer to cancel the policy and decline the claim.
It is therefore VERY important when taking out life cover that you accurately reflect the truth about your medical condition. If you have existing conditions, disclose them. The insurer may ask if they can make further enquiries to your doctor before deciding whether to proceed. They can only do so with your written consent.
People take out life insurance policies to provide peace of mind that in the untimely event of their death. To willfully mislead the insurer would seriously jeopardise the chances of this peace of mind being realised.
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