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Misrepresentation

Misrepresentation occurs when false, incomplete, or misleading information is provided to an insurance company, either intentionally or unintentionally, during the application process or while a policy is active. It can involve misstating or omitting facts related to medical history, lifestyle, occupation, or any other information that could influence the insurer’s decision to issue coverage or determine premiums.

How It Works

A misrepresentation is treated as material when the insurer, had it known the true fact, would have made a different decision about insurability, typically by charging a higher premium or declining to insure at all. It is a deemed condition of every insurance contract that if a person applying for insurance misrepresents or fraudulently omits to communicate any circumstance that is material to the insurer in judging the risk, the contract is void. Applicants for coverage have a duty to disclose the material facts the insurer requests to evidence insurability, and where an insurer demonstrates that a material fact was misrepresented it can rescind (void) the contract so that no coverage need be provided. In Canadian insurance, misrepresentation can arise at different stages, including the original application, at renewal, or when requesting a policy change or endorsement, and the consequences depend on the product, the wording, and the materiality of the incorrect information. Within the first two years of a policy, an insurer alleging misrepresentation generally need only prove the misrepresentation occurred by error, mistake, or forgetfulness, while after two years it must prove the insured intentionally or recklessly misrepresented a fact.

Example:

A worker enrolling in a group health and disability plan completes a medical questionnaire and answers no when asked about an ongoing back condition for which they had been receiving treatment. The plan is issued. Later, when the worker files a long-term disability claim, the insurer reviews the application during its investigation. Because the undisclosed back condition was a material fact that would have affected how the insurer assessed the risk, the insurer may treat it as a material misrepresentation and deny the claim or rescind the coverage, even if the eventual disability arose from an unrelated cause.

What to Watch For:

Misrepresentation is not limited to deliberate fraud. A careless or incomplete statement can create serious issues even if it was not intentionally deceptive, falling into innocent, negligent, or willful categories. The information at issue can relate to medical history, lifestyle, occupation, or other details that could influence the insurer’s decision to issue coverage or determine premiums. Deliberate disability benefits fraud sits at the more serious end, generally occurring when a plan member intentionally misrepresents their situation by concealing information or providing false or misleading information for financial gain, such as not reporting income or other benefits while receiving disability benefits.

Related Terms

Member

A member is an individual who is enrolled and covered under a group insurance plan, typically through their employer, association, or organization. The member is often referred to as the insured employee or plan participant and receives coverage for benefits such as health, dental, life, and disability insurance. The member may also extend coverage to eligible dependents, such as a spouse or children, under the same plan.

Contestability

Contestability refers to the period of time after an insurance policy is issued during which the insurer has the right to review and investigate the accuracy of the information provided in the application. If the insurer discovers that any information was omitted, misstated, or misrepresented during this period, it can deny a claim or void the policy.

Plan Member

A plan member is an individual who is enrolled in and eligible to receive benefits under a group insurance plan. Typically, the plan member is an employee of a company or a member of an organization that sponsors the group policy. The plan member is covered for the benefits outlined in the plan - such as health, dental, life, and disability insurance - and may also extend coverage to eligible dependents, including a spouse or children.

Policy (Contract)

A policy, also referred to as a contract, is the legally binding agreement between an insurance company (the insurer) and the policyholder that defines the terms, conditions, and obligations of coverage. It outlines what is insured, the benefits provided, the premium amount, exclusions, and the responsibilities of both parties. Once the insurer accepts the application and the first premium is paid, the policy becomes active and enforceable.

Insurer

An insurer is the insurance company or organization that provides financial protection to individuals or groups in exchange for premium payments. The insurer assumes the risk of potential loss and agrees to pay benefits for covered claims according to the terms of the policy. Insurers evaluate applications, determine premiums, issue policies, and manage claims through underwriting and administration processes.

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