Claim rejected without sufficient evidence on non-disclosure

Non-Disclosure

Background

The late Mr. Alexander suffered a fatal fall from a height. His next of kin brought a  complaint to us after the Death Benefit claim was rejected by the Takaful Operator. The Takaful Operator rejected the claim on basis that the late Mr Alexander had history of depression and failed to disclose this in the proposal form dated 8/12/2017. As the information disclosed in the proposal form was not done in good faith, the Certificate was declared void since inception.

Investigation and Key Findings

We probed into the evidence submitted by the Takaful operator and found  that their only source of information on the late Mr Alexander’s illness came from the Autopsy Report, i.e.:

a)        the deceased’s brother's statement that the deceased suffered from depression at the time of death; and

b)        the results of the deceased’s blood test revealed the presence of mirtazapine, an antidepressant drug used to treat depression, obsessive-compulsive disorder, and anxiety disorders.

The Takaful operator did not submit any other documentary or medical evidence to support their claim that the late Mr Alexander had suffered from depression for the past 9 years. In addition, the late Mr Alexander’s employer also confirmed that he was unaware that the deceased was suffering from any medical condition while working with him.

 

Recommendation

The brother of the late Mr. Alexander was not a medically trained person. Therefore, his statement cannot be considered as conclusive evidence that the deceased had suffered from depression. Furthermore, there was neither medical report nor doctor's testimony to confirm the exact date the deceased first diagnosed with depression and  was prescribed ‘mirtazapine’. 

In the light of the above finding, we informed the Takaful Operator that in the absence of medical evidence, it is difficult to determine whether the deceased’s psychological condition (depression) was diagnosed prior or after the commencement of the Certificate. As the Takaful Operator was unable to prove the non-disclosure of material facts in the proposal form by the late Mr Alexander, we recommended that the Takaful Operator review their decision.

The Takaful Operator accepted the recommendation and paid the claim.