Pre-existing medical conditions

A pre-existing medical condition (PEMC) is an illness or injury you had before your policy began or was renewed. Examples of pre-existing medical conditions include, diabetes, asthma, high cholesterol or a long-term back condition. 

We get complaints from customers who say their insurance company won’t accept their claim because it’s linked to a pre-existing medical condition.

Some insurance policies are individually underwritten. This means that when you apply for the policy, the insurer will ask you:

• questions about your health
• to declare any conditions you have at that time

This is often called ‘medical screening’. The insurer then tells you whether the conditions you’ve declared are covered in the policy. If they’re not covered, you may be able to pay an additional premium to have them included.

Whether a condition is covered – and whether it will cost more – depends on the insurer’s underwriting criteria for the specific policy.

Some policies aren’t individually underwritten. These policies have a blanket exclusion for all claims caused by, or related to, a pre-existing medical condition.

We hear from consumers who tell us that:

• weren’t aware of the exclusion or warranty relating to pre-existing medical condition
• didn’t understand the pre-existing medical condition exclusion and what it meant in practice
• weren’t sure what, if anything, they needed to declare
• felt the policy was mis-sold
• felt their insurer wrongly rejected their claim

If you have a complaint about pre-existing medical conditions, talk to your insurer first. They need to have the chance to put things right. They have to give you their final response within eight weeks for most types of complaint.

If you’re unhappy with their response, or if they don’t respond, let us know. We’ll check your complaint is something we can deal with, and if it is, we’ll investigate to understand what happened and what went wrong.

Find out more about how to complain.

To help us consider a complaint fairly, we’ll ask you to provide some information. We’ll make our decision about what happened using evidence provided by you, your insurer and any relevant third parties. In reaching a decision, we consider:  

• the policy’s terms and conditions – we’ll look at what your insurer asked you about your health when you took out, amended or renewed your policy, and if you’ve been mis-sold a policy. 
• exclusions for pre-existing medical conditions – If your insurer didn’t ask you anything about your health and there was no medical screening, we’ll consider whether it was fair for them to use an exclusion in your policy. 
• misrepresentation and non-disclosure – If there was a medical screening, we’ll check you gave the insurance company all the relevant information. If you didn’t, we’ll consider if you’ve deliberately misrepresented information or made a mistake. Read more about our approach to misrepresentation and non-disclosure complaints.
• change in health – an insurer  may turn down a claim because of a condition that came after the policy began or was renewed. 

If we find you’ve been treated unfairly, we'll ask the insurer to put things right. This usually involves putting you back in the position you’d be in if things hadn’t gone wrong. 

We’ll also consider whether you’ve experienced any distress or inconvenience as a result of what the insurer did wrong and whether we think it’s appropriate to award compensation. Read more about how we award compensation. 

Complaints about claims

If we think your insurer has unfairly turned down a claim, we may recommend that they:

• reconsider the claim in line with the terms and conditions of the policy
• pay the claim and add interest to cover the period from the date of the claim until the date the settlement is paid.

Complaints about mis-selling

If we think a policy was mis-sold because you wasn’t made aware of an exclusion. We may ask the insurer to:

• refund the premium plus interest, less any tax due.
• treat you the same as the other business would if you would have got cover from them.

Read more about insurance policies that have exclusions for pre-existing medical conditions:

• travel insurance 
• private medical insurance
• payment protection insurance (PPI) 
• pet insurance

If you’re a business looking for information to help you resolve complaints or want to find out more technical information, you can find more detail about complaints about pre-existing medical conditions in the business section of our website.