Careless Misrepresentation

Policy Start Date

2nd February 2022

Date first absent

14th August 2024

Cause of absence

Lower back pain

Medical History or other misrepresented facts

The client had previously had episodes of back pain in 2017 and 2019, the latter of which led to a couple of months off work and a referral for physio which lasted 6 weeks. During this time the client was advised to use over-the-counter pain relief.

Application questions answered incorrectly

In the last 5 years, regardless of whether you’ve seen a doctor, required treatment, or had time off work, have you had:
- Back pain, sciatica, whiplash, or anything else affecting your neck or back?

Other than the things you’ve told us about, in the last 3 years have you:
- Been prescribed medication or treatment for a period of 4 consecutive weeks or more, or have you been under review from your doctor or a medical professional?

Retro Underwriting decision

If the client had answered ‘Yes’ to the above 2 questions the underwriters would only have allowed cover subject to the following being excluded: ‘Any disease or disorder of the back, neck or spine including the supporting muscles, ligaments, joints or discs of the spinal column or related nerves including sciatica.’

Client explanation

The client said he hadn’t been clear on the dates and wasn’t sure if each episode was within the scope of the questions asked. He also said he had mentioned this to his adviser. The adviser had no record of the conversation and said he’d have obtained further details from the client if he’d have mentioned this history to him.

Decision

Careless misrepresentation

Reason

The insurer felt that the client and/or the adviser had shown insufficient care when answering these questions and checking the answers, and that a reasonable person would have considered the information was relevant to the insurer.

Outcome

The back exclusion was retrospectively applied and the claim declined. The client chose to continue with their policy despite this.