CR16

• Exclusions – fishing for information to support an exclusion

Background

Mr A enjoyed life cover under his policy with Company X. When he died (due to natural causes), his wife instituted a death claim and provided Company X with all the necessary documents to prove it. Company X requested further medical information from her and when she failed to provide it, informed the executors of Mr A’s estate that until the outstanding information was received it could not assess the claim.

According to Company X it is common practice to obtain further medical records in the event of natural death. Medical records were requested from the hospital where Mr A had died in order to investigate the circumstances surrounding his death. Upon receipt of the records Company X noticed that it was incomplete and therefore endeavoured, but failed, to obtain a full set of copies of the medical records from the hospital.

Assessment

Because Mr A’s wife had already provided Company X with all the documents to prove the death claim it appeared to us that it required the additional medical records to rely on an exclusion clause (possibly a pre-existing condition). We informed Company X that if it wanted to rely on an exclusion clause, it had to prove its reliance and that it could not expect the claimant to provide them with such proof. We informed Company X that it was not allowed to delay payment of the claim because it was experiencing difficulties in obtaining the still outstanding medical information required in order to rely on an exclusion clause.

Result

The complaint was upheld.

AS