Health Claim, a Fibroid History and a Proposal Filled by the Agent
A 45-year-old woman bought a family health takaful plan with PKR 1 million annual cover, a 90-day waiting period and a 20% co-payment. The proposal form, which her agent filled in at her kitchen table, records “no past medical history”. She signed where shown without reading it. Five months later she is hospitalised for a hysterectomy; the bill is PKR 480,000. Hospital records show that she was diagnosed with fibroids two years earlier and had been taking medication. She says the agent told her “don’t mention small things or the premium will go up”. The agent earned PKR 12,000 commission on the case. The operator’s claims department has issued a letter asking for all treatment records and has not yet decided. The client has threatened to post the story on social media and complain to SECP, and asks the agent to “fix it” because the agent filled the form. The agent still has the client’s original prescription slips in his WhatsApp chat.
1. Analyse the claim and the agent’s conduct. What is the proper claims-handling position?
Read the worked answer
The fibroid diagnosis and medication are material medical history. They existed before the proposal and were not disclosed. The 90-day waiting period is not the central issue because the surgery occurred about five months after inception; the central issue is non-disclosure at underwriting. The operator may be entitled to avoid the certificate or refuse the claim if the omission was material to acceptance or terms, but that decision belongs to the operator after reviewing the medical records and the proposal.
The agent’s conduct is a separate and serious matter. Filling the form is not itself wrong if he read the questions and recorded the answers accurately. Telling the client to omit “small things” is wrong, and recording “no past medical history” when he had the prescription slips is worse. The client signed the declaration, so she has responsibility too, but the agent’s advice may have induced the non-disclosure.
The 20% co-payment applies only if the claim is otherwise payable. The agent should not decide the claim or promise an outcome. He should provide the records he holds, cooperate with the operator and stop giving informal assurances.
2. What should the agent do now with the prescription slips and the client’s request to ‘fix it’?
Read the worked answer
He must not delete or withhold the prescription slips. They are relevant claim documents and may also be evidence in a conduct investigation. He should send them to the operator’s claims department with a covering note explaining when and how he received them, and keep a copy. He should tell the client that he has done so and that the claim will be decided on the full medical evidence.
He should not coach the client to change her story or ask the hospital to alter records. He should apologise for any misleading advice without admitting a legal outcome, and explain that the operator must apply the policy. If he completed the form, he should write a factual statement for his principal and the operator: who asked what, what answers were given, whether the client read the form, and why the medical history was omitted.
He should report the matter to the agency principal and compliance because his own conduct is under scrutiny. Concealing the prescription slips would turn a disclosure problem into a fraud problem. The client’s request to “fix it” should be answered by explaining the process, not by promising to influence the claims department.
3. How should the social-media threat and possible SECP complaint be handled?
Read the worked answer
The agent should acknowledge the client’s frustration and explain the complaint route in writing. She can complain first to the operator’s grievance or customer-service function, then to SECP’s insurance division or the Federal Insurance Ombudsman where the complaint falls within its jurisdiction. The agent should give her the relevant contact details and keep a record of the communication.
The threat of social media is not a reason to pay a claim that is not payable, and it is not a reason to abandon the process. The agent should not ask her to delete posts or offer money to silence her. He should avoid arguing in public or posting about the case. If the client posts inaccurate statements, the operator’s communications team should handle any response, not the agent.
The agent should also prepare for the possibility that the complaint will examine his advice. He should preserve all messages, the proposal form and the prescription slips, and provide a truthful timeline. The best protection is transparency: the operator decides the claim; the agent explains the process; any agent misconduct is dealt with separately. A customer-service response that mixes the two will make the dispute worse.