Account of the case
On 23 September 2024, A made an application for a medical expenses insurance for her child B (born in 2013). With the insurance application, A also filled in the health declaration regarding B, providing negative answers to questions related to diseases, traumas, symptoms and treatment contacts. The Policy was granted with standard Terms and Conditions, and it entered into force on 23 September 2024.
On 10 January 2025, A claimed compensation for B’s medical expenses, informing that they were related to cardiac symptoms. On 11 January 2025, the Insurance Company asked A to provide the receipts for treatment expenses as well as copies of the patient records filled in by the doctor. Having received the information requested from A, the Company asked A on 17 January 2025 to provide information on the time of commencement of the symptoms and where the disease or symptoms were previously treated, as well copies of the patient records filled in by the doctor as of the beginning of the treatment of the disease. Based on the information received, on 5 February 2025 the Company asked A to provide information on the examinations of B’s bilirubin values and Gilbert’s syndrome, as well as a power of attorney to request information from the place of treatment. A responded to the request of additional information on 6 February 2025. On 20 February 2025, the Company asked patient record information as per 10 February 2025 as well as the April 2024 patient record data concerning bilirubin. A provided the requested clarifications on 20 February 2025. On 28 February 2025, the Insurance Company requested additional patient record texts regarding the doctor’s appointment of 2 April 2024.
On 27 March 2025, the Insurance Company issued a decision finding that while providing her health information on 23 September 2024, A had neglected to meet her obligation to provide information as per Section 22 of the Insurance Contracts Act, showing non-minor negligence. The Company referred to the medical report on B, according to which B had, prior to concluding the Insurance Contract, been detected with an elevated bilirubin value, stomach-ache or reflux symptoms. Moreover, when a child, B had been diagnosed with a heart that was larger than normal. The Insurance Company declared that it would not have granted an insurance, had they had, when processing the insurance application, the correct information on B’s state of health. The elevated bilirubin value, the reason of which had not been verified and is still under investigation, would have led to a refusal of the insurance application. The Insurance Company informed that they would terminate the Insurance Contract under Section 17 of the Insurance Contracts Act, reimbursing the premiums already paid.
Customer’s complaint
A declares to be dissatisfied with the decision of the Insurer and requests that the Insurance Complaints Board issue a recommended solution in the case.
A reports that in November 2024, B started to have tachycardia, and the school healthcare nurse proposed that B should have an appointment with a doctor. The doctor prescribed, among others, blood tests including the testing of the bilirubin value since it had been elevated in April 2024. When B was of one year of age, the doctor performing a routine check considered that B might have a heart that was slightly larger than normal. This was noted in a routine check made in B’s birth country Russia for all one-year-olds, but no atypical clinical findings were made at that point. A mentioned this to the doctor, thinking that this information may be helpful for diagnosing B. However, B never had had cardiac symptoms, diagnoses or treatment prior to November 2024. In a X-ray exam made on 10 January 2025, B’s heart was found to be of normal size, and according to A this may suggest that A’s earlier information on the issue may have been a misunderstanding. Thyroid values and the bilirubin value were found to be abnormal. In April 2024, B had had stomach-ache, and during the respective exams, the elevated bilirubin value was detected. The result of the ultrasound exam was normal. B was prescribed a 20-day pantoprazole medication which alleviated the pain. No exact diagnosis was made. The doctor had recorded that it was recommendable to control the bilirubin value but A did not get this information personally.
When the insurance application was filed in September 2024, B was in good health and had no chronic diseases. The recording of B’s larger-than-normal heart is probably erroneous and this finding has never been confirmed. B’s elevated bilirubin value is a one-off case when B was examined for the stomach-ache. In January 2025, the value was found to be normal. A finds that the Insurance Company had no right to terminate B’s medical expenses insurance. The claimed compensations should be paid.
Reply by the Insurance Company
The Insurance reiterates the stand expressed in its decision.
The health declaration should have mentioned the elevated bilirubin value, B’s stomach-ache or reflux symptoms as well as the larger-than-normal heart detected in B’s childhood. The reason for the elevated bilirubin value had not been clarified and the respective investigation was ongoing when the insurance application was made. According to the Insurance Company’s rules on choice of liability, this would have prevented the granting of the insurance. As late as October 2024, the controls of the bilirubin value were recommended. Since the insurance would not have been granted, had the correct information on B’s state of health been known to the Company, the Insurance Company finds that their decision to terminate the insurance is in line with the Insurance Contracts Act.
Further clarifications acquired
1. Health declaration
A filled in the online health declaration regarding B on 23 September 2024.
A had given a negative reply to all questions in the health declaration regarding diseases, symptoms and traumas, including the question about the stomach and the digestive system diseases and hernias. Moreover, A had given a negative answer to the question “has the child been examined or treated for another disease, symptom, problem or trauma, potentially not mentioned by you in this health declaration” and “has the child some other symptom or has the child been suspected of having some disease or have exams or measures been planned”.
2. Medical information
The Insurance Complaints Board has been provided with B’s medical information for the period from 2 April 2024 to 11 February 2025.
According to the patient records at the acute outpatient service at the healthcare centre, dated 2 April 2024, B had stomach-ache started the previous week, manifesting itself in the middle of the stomach, mostly at the upper righthand side of the stomach. On 2 April 2024, B had gone to school having felt better but then felt a strong stomach pain and some dizziness. The previous week, B had been vomiting for five days. About one month earlier, B had had the previous stomach-aches, and at that point B had gone to a private medical station which had performed lab tests. The haemoglobin value had been 160 while bilirubin was at 25.3. The stool cultures were normal. B had not had any fever or urinary problems, and the stools were normal. Eating had not made the symptoms any worse. There was some belching. The examination at the doctor’s showed that the stomach was soft and yielding. The upper central and lower central parts of the stomach were found to be slightly sore. No resistances were found, and the bowel sounds were normal. In the doctor’s estimate it was a question on nonspecific symptoms. B’s mother had ensured that B did not suffer from stress. B was given the instructions to try pantoprazole medication for 7 days. Moreover, lab tests had been programmed, with a telephone contact times with the personal doctor. According to a marking of 16 April 2024 by the Health Centre doctor, they had tried to contact B’s mother for the lab test results. B had been given a referral for the ultrasound of the stomach. According to a recording of 17 May 2024, the Health Centre doctor had sent a text message to B’s mother, saying that the ultrasound result was normal and that lab tests should be made in October 2024 to control the bilirubin values.
According to the patient records of 10 January 205 at a paediatric specialists, B had come to the doctor’s for a tachycardiac symptom. The anamnesis mentions that B’s bilirubin value had been slightly elevated. The Gilbert’s syndrome, diagnosed in B’s father and brother, was excluded through gene tests. However, B’s bilirubin was slightly over the reference value upper limit, and the conjugated bilirubin was clearly elevated. The value had not yet been controlled. When small in Russia, B had been examined routinely as a part of the normal child welfare clinic follow-ups, and it was told at that time that B’s heart was larger than normal but the follow-up will be sufficient if no symptoms appear. A few months earlier, B had started to have sudden tachycardia episodes 2 or 3 times a week, with the measured heart rate at 120-140/min. The tachycardia had started and ended suddenly. In the examination, the heart rate was an even 58/min and the blood pressure was 97/70 mmHg. Lab tests and the chest X-ray were programmed for B. According to a record of 13 January 2025, the findings of the X-rays were normal. According to a record of 11 February 2025, B had had an event ECG recording with nothing that would explain the symptoms. Among the bilirubin values, S-Bil-Kj was 6.0 umol/l (reference value under 5) and S-bil 18.5 umol/l (reference value 5-25). A referral for further investigation at the paediatric outpatient hospital was written for B. The diagnosis written was E80.6, Disorder of bilirubin metabolism, unspecified. According to the recording of 11 February 2025, the paediatric outpatient clinic did not find any further investigations necessary for the time being. At the request of B’s mother, further thyroid exams were programmed.
Recommended solution
Formulation of question
The question here is whether A has, while given B’s health declaration of 23 September 2024, neglected to fulfil the information obligation as per Section 22 of the Insurance Contracts Act, demonstrating non-minor negligence, and whether the Insurance Company has had the right to terminate the insurance and refuse to pay the claimed compensations.
Sections of Law
According to Section 17 Subsection 1 (14 May 2010/426) of the Insurance Contracts Act (28 June 1994/543), the Insurer is entitled to terminate insurance of the person, if:
1) the Policyholder or the Insured has prior to the issuance of the insurance, wilfully or through negligence that is not be considered slight, given the Insurer incorrect or incomplete information and the Insurer would not have granted the insurance, had it been aware of the true circumstances;
2) the Policyholder or the Insured has acted in bad faith while fulfilling its duty of disclosure, but the insurance contract is still binding on the Insurer pursuant to Section 24, Subsection 3; or
3) if there has been a change in any circumstance relating to the Insured that is of relevance to the assessment of the Insurer’s liability and the change would increase the underlying risk as referred to in Section 27 and the Insurer would not have granted the insurance, had the circumstance relating to the Insured conformed to the change at the time the insurance was granted.
According to Subsection 3 of the Section of law, after becoming aware of a circumstance which justifies termination, the Insurer shall give written notice of the termination of the insurance without undue delay. In its notice of termination, the Insurer shall indicate the reason for termination. If notice of termination is not given as provided in this Subsection, the Insurer forfeits the right to terminate. The insurance expires one month after the date that the Insurer sent the Policyholder a notice of termination.
Under Section 22 of the Insurance Contracts Act, before the issuance of an insurance contract, the Policyholder and the Insured shall give true and complete answers to the Insurer's questions which may be of importance for the assessment of the liability of the Insurer. Moreover, throughout the insurance period, the Policyholder and the Insured shall without undue delay rectify any errors or deficiencies that they may discover in the information given to the Insurer.
Under Section 24 of the Act, if the Policyholder or the Insured has acted in bad faith under an insurance of the person, the Insurer is not bound by the Policy. The Insurer is entitled to retain all premiums paid even if the insurance expired. (Subsection 1) If the Policyholder or the Insured has, either wilfully or through negligence which cannot be considered slight, failed to fulfil the duty of disclosure, and if the Insurer had not issued the insurance had true and complete answers been given, the Insurer is discharged from liability. If, however, the Insurer had issued the insurance in any case but only against a higher premium than agreed or otherwise on different terms, the Insurer's liability is limited to an amount which corresponds to the agreed premium or to the terms and conditions on which the insurance would have been issued. (Subsection 2)
Evaluation of the case
1. Neglect by the Policyholder to disclose information
The Insurance Complaints Board notes that under Section 22 of the Insurance Contracts Act, the party applying for the insurance shall give true and complete answers to the Insurer's questions in the health care report. Has he or she failed to fulfil this legal obligation, the consequences of the negligence must be assessed, as far as the liability of the Insurance Company are concerned in cases of insurance of the person, under Section 24 of the Insurance Contracts Act and for the change of Policy terms, under Section 17.
When assessing whether or not the Policyholder has neglected the duty of disclosure as well as assessing the quality of his or her eventual negligence, the information available to them and in force during the closing of the contract and the relevant circumstances must be taken into account, among other questions. Attention must also be paid to the quality and clarity of the questions posed by the Insurer. It can be deemed that there is no negligence or it is of minor importance if, for example, the Insurer’s question is so general or open to interpretation that it is difficult to provide an accurate or complete answer.
A filled and signed B’s health declaration on 23 September 2024. A gave a negative answer to, for example, the question whether the insured child had had stomach or digestive organ diseases or symptoms, as well as to the question whether the child has another symptom or whether there has been a suspect of another disease or plans for exams or measures.
According to the medical information provided to the Insurance Complaints Board, B had been at a health centre in April 2024, to be seen because of a strong stomach-age symptom. About one month prior to this, B had been at a private medical centre for a stomach-ache symptom, and it was found that B’s bilirubin value was elevated. B had a stomach ultrasound, with normal findings. The controls of the bilirubin value was programmed for October 2024.
Referring to what has been reported above, the Insurance Complaints Board finds that A should have reported B’s stomach-aches in the health declaration, since they had required several healthcare contacts in 2024, as well as the fact that in May 2024, B had been prescribed a bilirubin value control in October 2024. The Complaints Board finds that the questions made are clear and unequivocal. Considering the fact that the time between the symptoms and healthcare contacts and the insurance application is fairly short as well as the several contacts with the healthcare system, the Complaints Board finds that A’s negligence in filling in the health declaration must be considered non-minor. Therefore, the question to be assessed has to do with the consequences of the neglect of the information obligation.
2. Consequences of the neglected obligation to provide information
Under Section 17.1. and Section 24 of the Insurance Contracts Act, if the Policyholder or the Insured has, either wilfully or through negligence which cannot be considered slight, failed to fulfil the duty of disclosure, and if the Insurer had not issued the insurance had true and complete answers been given, the Insurer is discharged from liability and has the right to terminate the insurance.
The Insurance Company has noted that it would not in any way have granted the applied insurance had it known that B had been diagnosed with an elevated bilirubin value, with the reason unknown, and with the respective exams underway while the insurance was applied for. The bilirubin assay is used, for example, to shed light on liver and bile duct diseases as well as conditions causing haemolysis. The bilirubin value may get elevated, for example, due to prevention of the flow of bile, liver cell damage or excessive haemolysis. The Insurance Complaints Board finds that the Insurance Company’s information on their risk selection solution is credible. The reason of B’s elevated bilirubin value, detected prior to the application of the insurance, remained unclear. In such a situation, it is not possible to make a choice of liability decision based on the state of health of the Insured, since the risk is not known.
The Insurance Company has informed the A about the termination of the Insurance Policy as required by the law in question and without undue delay. The Insurance Complaints Board finds that the Insurance Company has acted in compliance with the Insurance Contract Act.
Final outcome
The Insurance Complaints Board does not recommend any change in the case.
The Insurance Complaints Board’s decision is unanimous.
INSURANCE COMPLAINTS BOARD
Chairperson Luukkonen
Secretary Laine
Members:
Helenius
Kummoinen
Rahijärvi
Sibakov