Background
The complainant applied for life cover to the insurer in July 2007. During August 2013 she added additional benefits, inter alia a dread disease benefit to the policy. In March 2016 she increased the dread disease cover and in her application form to increase the benefit, she answered in the negative to all of the following questions:-
“a) Since completing the medical questions on your existing policy application, have you been diagnosed with any disease(s) or disorder(s) that requires ongoing or intermittent management (medication, monitoring or other treatment(s))?
…
- Have you had or are you scheduled for any medical investigations or examinations in the next eight weeks, for example x-rays, scans, biopsies or other surgical procedure, blood investigation or specialist assessments?
…
- Are there any circumstances that may have arisen since the last disclosure you have made for this policy, which may affect the assessment of risk for the cover or benefits you are applying for in this application form? You have to tell us again of any health circumstances that you have disclosed in your original application form…”
Since no adverse medical information was provided in the application form to increase the benefit, the dread disease benefit was increased.
On 10 May 2016 the complainant submitted a dread disease claim to the insurer after being diagnosed with breast cancer. On investigation of her claim, the insurer established that on 19 June 2013 the complainant underwent test to determine the presence of the BRCA2 gene. A pathology report dated 03 September 2014, received by the insurer at claim stage, confirmed a sequence variance in the BRCA2 gene. On 07 March 2016 the complainant consulted a general surgeon “with the intention of discussing a possible risk prevention plan to be pro-active against the BRCA2 risk.”
The insurer declined the claim in respect of the increased portion of the dread disease benefit.
The complainant approached our office for relief and alleged that “In a totally unrelated exercise, I consulted a surgeon, Dr A, on 7 March 2016 with the intention of discussing a possible risk prevention plan to be pro-active against the BRCA2 risk. The BRCA2 statistics prove average cumulative risks by age 70 years are 45% for breast cancer and 11% for ovarian cancer. The risk of contracting breast cancer at my age was therefore being placed on par with other woman same age bracket. In the medical profession it was considered ‘radical’ to get a prophylactic double mastectomy as well as ovary removal. At such stage neither I nor the doctor was concerned about having cancer as all previous test results were clear and I was given time to think about the options.
On 18 April 2016 Dr A attended to a core needle biopsy and on the said date only was it discovered that I had breast carcinoma.
I pause to point out that the service alteration request was attended to and completed on 23 March 2016, and thus nearly a month prior to having been advised of the breast carcinoma. I therefore could not possibly in fact have any knowledge of the condition during the service alteration request of 23 March 2016 and have duly, properly and honestly answered all requested information;
I had at the time of completion of the request also not been diagnosed with any disease or disorder which requires on going treatment nor was any medical investigations or examination scheduled. The consultation with Dr A of 7 March 2016 was simply for advice on a prevention plan – which was still deemed ‘radical’ in South Africa.”
The insurer responded as follows to the above:
“…Dr. A confirms the Complainants awareness of the risk that the BRCA gene carried by her enquiry as to the necessity of undergoing a bilateral prophylactic mastectomy. In the face of the clear questions in the (application form to increase the benefit) she should have told us of this.
We submit that her consultation with Dr A (which was impelled by her concern for her carrier status) was a circumstance that in the estimation of the reasonable and prudent person was apt to be disclosed.”
Discussion
Since an insurance contract is one of good faith, a life assurer, in order to assess the risk, relies almost exclusively on the information provided by the proposer when applying for the insurance. The proposer is therefore duty bound to voluntarily disclose all material information relevant to the risk that is to be underwritten. The strict requirement for full and honest disclosure is a fundamental principle of insurance.
It is probable that, had the complainant made full disclosure of her consultation with the general surgeon on 07 March 2016, the insurer would have requested further information before taking a decision as to whether the benefit should be increased.
Our office made a preliminary ruling that there were no legal or equitable grounds on which the insurer could be requested to make any concessions to the complainant.
Result
The complaint could not be upheld.
