Western Provident Association Limited · DRN-6255532

The complaint Mrs L is unhappy with Western Provident Association Limited’s decision to decline her claim and add an exclusion to her policy. What happened Mrs L has had private medical insurance for herself and her family with WPA since April 2022. She claimed on her policy for a referral to a renal specialist, however, the claim was declined as WPA said it was unaware of her previous medical history that predated the policy’s inception. Mrs L said she didn’t disclose her abnormal creatine and estimated glomerular filtration rate (eGFR) readings taken in January 2020 because they were brought back under control within the following month. Mrs L said WPA’s decision to add a personal exclusion to her cover because of this non-disclosure is unfair. WPA said Mrs L should have disclosed this information when asked in 2022. It said had it known about the irregular readings, it would have added the exclusion from inception. Our investigator didn’t uphold this complaint. She said whilst Mrs L disclosed several other medical conditions, she’d not told the insurer about the issues with her creatine and eGFR readings. She also highlighted Mrs L’s medical records show her GP offered to refer her to a specialist at that time. Our investigator said WPA could reasonably add the exclusion retrospectively. Mrs L, unhappy with that, asked for an ombudsman to review her complaint. In summary, she said the abnormal readings were brought back under control within one month and so there wasn’t any issue to be disclosed. She also said she didn’t see a specialist back in January 2020 and that the referral was offered because of her father’s history of chronic kidney disease. And so, it’s now for me to make a final decision. What I’ve decided – and why I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint. Having done so, I’ve decided not to uphold it and for broadly similar reasons to those given by our investigator. I’m satisfied Mrs L didn’t answer, when asked, with accurate information about her past medical history. The available medical evidence shows Mrs L was under investigation for her kidney function and I think this should have been disclosed at inception. WPA became aware of this when it reviewed Mrs L’s claim to see a specialist in 2025 and so it can reasonably add the exclusion it otherwise would have added to the policy in 2022. I’ll explain why. The relevant law that applies in this case is the Consumer Insurance Disclosure and Representations Act 2012 (CIDRA). This law sets out the actions available to the insurer should a misrepresentation occur. I’ve considered WPA’s actions to ensure they’re

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consistent with the available remedy under CIDRA. WPA said this is a qualifying misrepresentation, which means it would have done something differently had it known the full extent of Ms L’s medical history. The question Mrs L was asked when she applied for the policy in March 2022 was: “Have you or any family member(s) applying for cover seen a specialist, been treated in hospital or had any tests/investigations (e.g. scans, x-rays, blood tests, biopsies, diagnostic genetic or screening tests) for any condition(s) symptoms or allergies within the last five years?” And: “Have you or any family member(s) applying for cover consulted a GP or other healthcare professional in the last year?” Mrs L answered yes to both questions and disclosed hypertension, basal cell carcinoma of skin, osteoarthritis of the knee and excessive menstrual bleeding. But having carefully reviewed Mrs L medical records, I note she was offered a referral to see a renal specialist in January 2020, following an abnormal blood test reading. I understand Mrs L ultimately decided not to see the specialist at that time, but I’m satisfied her medical records show she had blood tests to monitor her creatine and eGFR levels within the five years that predate the policy’s inception. There were further instances where her creatine and eGFR levels were monitored in February 2020, December 2021 and February 2022. These occasions also predate the inception of the policy and should have reasonably been declared to the insurer when asked. WPA said it would have done something differently had it known the full extent of Mrs L’s medical history, namely it would have added the exclusion, so I’m satisfied this is a qualifying misrepresentation. Having carefully considered Mrs L’s reasons for not disclosing this information to the insurer, I’m satisfied the misrepresentation was careless, rather than deliberate or reckless. That means WPA can fairly add the exclusion retrospectively because this is a remedy available to it under CIDRA for a qualifying careless misrepresentation. I know this isn’t the answer Mrs L was hoping to receive and I take on board she went to some effort ensuring she shared as much information as she could recall about her other medical conditions. That’s why I’m satisfied the non-disclosure wasn’t a deliberate attempt to mislead the insurer. I’ve reviewed evidence from WPA’s underwriters which persuasively shows it would have added the exclusion from the outset and so I’m satisfied Mrs L been treated fairly and in line with the remedy set out under CIDRA. My final decision For the reasons I’ve explained, I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs L to accept or reject my decision before 27 April 2026. Scott Slade Ombudsman

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