These case studies have been modified so as not to identify any actual cases at FIDReC. They are provided for purposes of learning and are not necessarily indicative of outcomes at FIDReC.
Ten years ago, Tom purchased a Hospitalisation and Surgical Reimbursement Policy. A few years later, Tom was diagnosed with a serious medical condition. Fortunately for Tom, the Policy covered the treatment for his medical condition.
Last year, Tom failed to pay the premium within the Policy’s 1-month grace period. As a result, the Policy lapsed. Tom asked the Insurer to reinstate the Policy, but the Insurer declined.
Tom came to FIDReC. He argued that his Agent failed to alert him of the missed premium during the Policy’s grace period. Tom had missed a premium payment some years before. At that time, his Agent had reminded him before the grace period ended. Tom also claimed that he did not receive any premium notices from the Insurer. He only discovered the lapse when checking the Insurer’s online portal.
At mediation, the Insurer explained that reinstating the Policy was subject to approval. This required medical underwriting. In Tom’s case, because of his serious medical condition, the Insurer was unable to extend coverage to him.
The Insurer further shared that it had sent letters to Tom at his address on record. Copies of these letters were also available on the online portal. While the Insurer’s agents did try to contact their clients for missed premiums, this was not their obligation.
Following the discussion at mediation, Tom chose to refer his case for adjudication. He submitted $100,000 as the amount claimed. This was the largest sum a FIDReC Adjudicator could award per claim. Tom argued that this was for his future medical expenses that the Policy would have covered.
After considering the submissions from both Tom and the Insurer, the Adjudicator dismissed Tom’s claim. Based on the evidence, the Adjudicator found that the Insurer had sent the premium notices to Tom. Because Tom failed to pay the premium within the grace period, the insurance contract allowed the Insurer to end the Policy. The Adjudicator also found that the Agent did not have to remind Tom about his missed premium. Finally, the Adjudicator observed that Tom had failed to prove the quantum of his claim. The losses that Tom said would be incurred in the future were speculative.
Key Learning Points
- Premium payment is the responsibility of a policyholder. In some insurance policies, the insurer must give its policyholder written notice that premiums are due. Insurers will issue such notices either by post or digital means.
- Policyholders should be mindful of notices and letters sent by the Insurer. They should keep their contact details with Insurers up to date. Policyholders may also schedule personal reminders to alert themselves when premiums are due.
- During mediation, FIDReC can handle disputes with no monetary claim, including claims for reinstatement of a policy. However, at adjudication, an Adjudicator can only make binding monetary awards. The Adjudicator cannot order that a financial institution do or not do any actions.
- At adjudication, a complainant must prove their claim and the amount of financial losses suffered. Only then may an Adjudicator make a monetary award in the complainant’s favour.
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