CR141 Fraud – quite probable – but claim paid

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CR141

Fraud – quite probable – but claim paid

Background

Medical evidence which was featureless, and which included a negative HIV test, was supplied at the time the application for life cover was submitted. The proposer was accepted at tabular rates and the contract was effected. Eight months after the commencement date the life assured died of cryptococcal meningitis with a positive HIV test, a CD4 count of 36 and viral load 110 000.

It is extremely unlikely, very rare indeed, that HIV infection would have been contracted after the inception date of the insurance and progress to full blown AIDS syndrome and death within eight months.

Understandably the life assurance company viewed the claim with suspicion and because of their feeling of unease they attempted, but without success, to obtain further evidence relating to the life assured’s medical status at the time the contract was effected.

Assessment

Whilst the Ombudsman fully appreciated the insurer’s reasons for seeking further medical information in order to determine the sustainability of the claim it was pointed out to the insurer that these investigations must be undertaken within a reasonable timeframe. A decision regarding liability could not be deferred indefinitely. Fifteen months after the date of death we informed the insurer that they had to reach a decision.

This is a case where the likelihood of fraud was very real. One has to question the validity, or accuracy, of the initial HIV test and also question whether there were symptoms of AIDS sickness – and possibly treatment – prior to the policy being effected. However, the burden of proof is on the insurer and as investigations over a lengthy period failed to produce any concrete evidence the insurer admitted liability.

Result

The claim was settled in the complainant’s favour.

DM
April 2006

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