Dangerous Medical Records

The April/May issue of Ombudsman News, the bulletin from the UK's Financial Ombudsman Service ("FOS"), contains a case summary (ref. 61/04) of particular interest to me.

A claimant ("Mr L") under a critical illness policy was accused of reckless non-disclosure. Among other things, he had declared that he had not smoked in the 12 months prior to proposing for the policy (although he had been an occasional smoker of cigars just prior to that), whereas the insurer alleged that its investigations showed that he regularly smoked one cigar a day at the start of the 12-month period in question.

It turned out that the insurer's information came from Mr L's own medical records. However, his GP revealed to the FOS

that the computer system on which he entered details of patients' tobacco consumption was unable to record a minimum consumption of less than one cigar or cigarette per day

(emphasis added)

Before going any further, let me send my congratulations to the anonymous FOS case officer who got to the bottom of that story. More than one of his or her colleagues would have assumed that the medical records were more reliable than the policyholder, and would have quickly closed the case by rejecting the complaint.

By coincidence, a case in which I am currently advising raises similar concerns. The policyholder is accused of non-disclosure and I have just received copies of the evidence on which the insurer relies. All of that evidence consists of extracts from the "policyholder's own" medical records. (I put those words in quotation marks because, as is almost invariably the case, the policyholder had never seen these records before.) Some of the most crucial material is contained in a letter written by a specialist to the GP. The letter purports to briefly summarise the policyholder's recent history before going on to record the medical findings. It's unclear where the "history" is supposed to have come from, as it is inconsistent with other records. Despite that, it is what the insurer has chosen to "hang its hat on".

One wonders how often this happens without being discovered.