Cook v Financial Insurance Co Ltd

An exclusion for disability resulting from a sickness, disease, condition or injury “for which” the insured received medical advice, treatment or counselling requires a sufficient link between the recognised medical condition and the earlier medical attention. Consultation about general symptoms is insufficient merely because those symptoms are later attributed to the disabling disease.

An exact diagnosis is not invariably necessary. The question is whether the patient was being advised or treated for a medically recognised condition, rather than for symptoms which might indicate several diseases or none. Consumer insurance documents incorporated into one contract must be read together and construed as the consumer would reasonably understand them.

A self-employed builder obtained insurance against inability to repay a business loan through illness. Before the cover commenced, he had consulted his general practitioner about collapse, pain and breathlessness. The doctor treated a possible infection and referred him to a cardiologist, without suspecting or informing him that he might have angina. Angina was diagnosed one day after the cover commenced.

The insurer refused his claim under a clause excluding disability resulting from any sickness, disease, condition or injury for which medical advice, treatment or counselling had been received during the preceding 12 months. The county court gave judgment for the insured. A majority of the Court of Appeal reversed that decision.

The central issue was whether earlier advice or treatment for symptoms, whose true cause had not then been recognised, amounted to advice or treatment “for” the disease which subsequently caused the disability.

1. Appeal allowed by a majority of three to two. Lord Lloyd of Berwick delivered the leading speech. Lord Steyn and Lord Hope of Craighead agreed with his reasons. The insurer had not established that the exclusion applied.

2. Per Lord Lloyd, the certificate had to be construed as a consumer would reasonably understand it. Because the application form was incorporated into the insurance contract, the form and certificate had to be read together so that the contract made sense as a whole. The insured’s declaration concerning consultations for illnesses therefore formed part of the relevant interpretative context.

3. Per Lord Lloyd, the words “for which” linked the disabling disease or condition to the earlier advice, treatment or counselling. The insured had received neither counselling nor treatment for angina. Antibiotics and a Ventolin inhaler prescribed for other suspected causes could not constitute treatment for angina. Nor did a referral for a second opinion amount, on the judge’s findings, to advice for angina when the general practitioner did not suspect that disease.

4. Per Lord Lloyd, advice about symptoms which later proved to have been caused by angina was insufficient. In its contractual context, “condition” meant a medical condition recognised as such by doctors. An exact diagnosis was not invariably required: a patient admitted with an evident but initially unidentified serious illness might already be receiving treatment for that condition. By contrast, general symptoms capable of indicating numerous diseases or none did not themselves constitute the relevant condition. Where a case lay on that spectrum was a question of fact for the trial judge.

5. Per Lord Lloyd, the application form reinforced that construction. Having declared only that he had not consulted a doctor except for minor illnesses, the insured could reasonably understand the exclusion as relating to major illnesses for which a doctor had been consulted. If ambiguity had remained, the exclusion would have been construed against the insurer.

6. Lord Browne-Wilkinson and Lord Jauncey dissented. They considered it sufficient that the insured was in fact suffering from the same physical condition before cover commenced and had received advice or treatment for it, although its precise nature had not yet been diagnosed. They would have dismissed the appeal.

1. House of Lords: By a majority of three to two, allowed the insured’s appeal: [1998] UKHL 42; [1998] 1 WLR 1765.
2. Court of Appeal: By a majority, reversed the county court’s judgment. Hobhouse LJ and Hutchison LJ held that the earlier medical advice or treatment fell within the exclusion. Evans LJ dissented.
3. Birmingham County Court: Judge Boggis QC gave judgment for the insured in the agreed sum of £6,101, holding that he had not received advice, treatment or counselling for angina before cover commenced.