A matter of the heart

Seline took out a health insurance policy in 1997. She was happy with her policy until 2016, when her insurance adviser told her that her monthly premiums were too high, and recommended she move to a new insurer.

Seline agreed to move to the new insurer. When she took out her new policy, she declared a number of medical conditions, including her high blood pressure, details of her most recent blood pressure reading, and that she was a heavy smoker. 

 

Heart attack

In May 2017, a year after she took out her new insurance policy, Seline had a heart attack. She was rushed to hospital, where she was told she would need quadruple bypass surgery. Seline told her doctors she had private medical insurance, so she was referred to a private hospital.

Seline submitted a claim to her new insurer for the cost of her upcoming bypass surgery, $64,000. However, the day before the surgery was scheduled to take place, the insurer declined Seline’s claim. The insurer said that when Seline took out her policy, she had incorrectly disclosed her blood pressure readings, and failed to disclose that she had been diagnosed with an ‘enlarged heart’ several years earlier. Due to this lack of disclosure, the insurer voided Seline’s policy, and refused to pay for her surgery.

Seline chose to proceed with the surgery anyway, increasing her credit card limit to pay the $64,000.

 

Dispute 

Seline was unhappy with her insurance adviser’s advice. She said the adviser should never have recommended she move to a new insurer. If the adviser had recommended Seline stay with her original insurer, she would have had full cover for her bypass surgery.  

Seline also said that her adviser should have done more to make sure she fully disclosed her medical conditions on her insurance application. Seline said that the insurance adviser should have asked the new insurer to obtain and review Seline’s full medical records before agreeing to offer her insurance.

Seline wanted the adviser to refund her $64,000 surgery costs.

 

The insurance adviser’s view

The adviser said he had fully discussed the pros and cons of moving to a new policy with Seline. He said that Seline never told him about her enlarged heart, or about her family’s history of heart disease. He said that if he had known, he would have reconsidered his advice.

Seline brought her complaint to FSCL.

 

Review

We found that the adviser had not misled Seline, or provided any unreasonable advice.

There were risks and benefits to moving insurers. The adviser had weighed these risks against the benefits of lower monthly premiums, and decided to recommend Seline switch insurers. Although the switch had severe negative consequences in this case, the advice was appropriate, based on the information the adviser had at the time. 

We also found that the adviser was not required to request the insurer to seek out copies of Seline’s medical records. Even if the adviser asked the insurer to review Seline’s medical records, the insurer likely would have refused. As the law currently stands, insurers do not have any duty to seek out an insured’s medical information. It is the consumer’s responsibility to fully disclose their medical conditions when they take out a policy. The adviser had told Seline she needed to fully disclose her medical conditions, and this was all the adviser was required to do.

 

Resolution

We ultimately found the insurance adviser had acted appropriately, and had not breached any of his professional obligations. We issued a formal recommendation, finding Seline’s complaint should be discontinued.

 

Insight for consumers 

When taking out a health insurance policy, it is very important to fully and accurately disclose all your existing medical conditions. If you miss anything, there can be severe consequences when you need to make a claim – you may find that your policy is void and you have no cover. It can be best to provide a copy of your medical records along with your health insurance application form, to ensure nothing is missed, and everything is disclosed.

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