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CR361 Dread disease /Exclusion Clause

CR361 Dread disease /Exclusion Clause Claim for dread disease benefit on grounds of cancer – claim not meeting policy criteria – claim settled Background 1. The policyholder initially consulted her general practitioner who referred her to a Specialist Physician as she was suffering from a chest infection. She was later hospitalised and treated for pneumonia. […]

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CR359 Dread Disease

CR359 Dread Disease When did Dread Disease claim arise? The insured suffered from sinus and swelling in his neck and consulted a doctor. He was treated with antibiotics. About one month later the insured turned 65 and the policy’s cover for the benefit expired. The swelling in the neck did not dissipate and the insured […]

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CR349 Dread disease / Equity

CR349 Dread disease / Equity Claim for impairment and/or dread disease benefit on grounds of dysfunctional colon disease – claim not meeting policy criteria – claim settled for 50% of sum assured on basis of equity Background 1. The complainant had a dysfunctional colon, and had several surgical procedures over about five years. A nerve […]

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CR346 Underwriting Alleged unreasonable delay in processing application for dread disease cover

CR346 Underwriting Alleged unreasonable delay in processing application for dread disease cover – in the interim complainant diagnosed with breast cancer and cover not granted. During August 2010 the complainant, who already had other risk policies with insurer A, obtained a quote for dread disease cover from insurer B, and then approached insurer A to […]

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CR334 Dread disease Medical evidence not meeting criteria for claim on basis of stroke

CR334 Dread disease Medical evidence not meeting criteria for claim on basis of stroke – claim repudiated – insurer asked to consider whether the evidence supported any other condition listed under “Nervous System” – insurer requesting neurologist report – complainant undergoing neurology assessment resulting in diagnosis of motor neuron disease – claim paid Background 1. […]

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CR251 Dread disease claim – interpretation of contract

CR251 Dread disease claim – interpretation of contract – complainant making second claim in respect of dread disease benefit – insurer refusing to pay claim on ground that benefit cancelled after first claim – policy wording did not support this interpretation – if any ambiguity in policy, wording to be construed contra proferentem Background The […]

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CR241 Dread disease Complainant claiming for dread disease benefit on grounds of cancer

CR241 Dread disease Complainant claiming for dread disease benefit on grounds of cancer – policy excluding “(a) all skin cancers, and (b) cancer–in-situ, including all melanomas-in-situ”- established that, while complainant’s was not a cancer-in-situ or a melanoma-in-situ, the tumour had not spread beyond the skin and therefore remained a skin cancer; insurer’s liability excluded Background […]

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CR182 Dread disease benefit claim

CR182 Dread disease benefit claim – insurer refused claim, as condition did not qualify, but was only prepared to offer more life cover at substantially higher rates Background The complainant, Mrs M, took out an insurance policy in 2001. In 2004 she was diagnosed with breast cancer. A mastectomy was performed and she submitted a […]

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CR160 Dread disease claim – heart attack definition not met

CR160 Dread disease claim – heart attack definition not met Background The definition of heart attack in dread disease polices has been a recurring problem for the Ombudsman’s office and is a problem which goes back many years. Dread disease contracts usually define heart attacks as “… the death of a portion of heart muscle […]

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CR79 Dread disease claim rejected. Catheterisation and angioplasty cannot be regarded as open-heart surgery

CR79 Dread disease claim rejected. Catheterisation and angioplasty cannot be regarded as open-heart surgery. Background The policy which was issued some years ago featured a dread disease benefit, one of the events covered being heart surgery, which was defined as ‘open surgical correction of structural abnormalities of the heart or coronary arteries.’ The policyholder submitted […]

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