Cook v Financial Insurance Company Ltd

The case concerned the construction of an exclusion clause in a group disability insurance certificate and policy which excluded benefit for "any sickness, disease, condition or injury for which [the insured] received advice, treatment or counselling from any registered medical practitioner during the 12 months preceding the commencement date." The key legal principle decided is that, in the context of that clause, advice or treatment must be given "for" the recognised medical condition itself as understood at the time; advice or treatment given for non-specific symptoms which only later are shown to be due to a particular condition will not ordinarily satisfy the exclusion. The House of Lords applied ordinary principles of contractual interpretation, read the certificate together with the incorporated application form, and, where there was ambiguity or doubt, construed the clause against the insurer.

The appellant (insurer) resisted a claim under a bank-arranged group disability insurance policy taken out by the respondent (insured) after the insured developed angina. The insured had collapsed in July 1992, consulted his general practitioner in July and on 4 September 1992 for symptoms (pain and breathlessness), and was referred to a cardiologist who diagnosed angina on 16 October 1992, one day after the policy commencement date of 15 October 1992. The insurer relied on an exclusion for conditions for which advice, treatment or counselling had been received in the 12 months prior to commencement.

The nature of the claim: The insured sought benefits for disability caused by angina; the insurer denied liability under the exclusion clause and the insured sued for the benefit.

Procedural history: Judgment for the insured in the county court (Judge Boggis Q.C., 15 November 1996); reversed by a majority in the Court of Appeal; appeal to the House of Lords.

Issues framed:

• Whether the insured received advice, treatment or counselling for angina prior to the commencement date; and
• Whether advice or treatment for symptoms which only later were diagnosed as angina is sufficient to bring the case within the exclusion.

Court’s reasoning and disposition: The majority in the House of Lords held that the words "for which" in the exclusion require that the advice or treatment be for the recognised condition itself at the time given. On the facts the general practitioner had treated symptoms and sought a second opinion to exclude possibilities; she had not treated or counselled for angina as a recognised diagnosis before commencement. Advice to see a specialist about undiagnosed symptoms was not advice "for" angina. The certificate and incorporated application form were read together, and any ambiguity was construed against the insurer. Accordingly the appeal by the insurer failed and the insured's claim succeeded in the House of Lords.

Appeal allowed in favour of the insured by a majority. The House of Lords held that, in the exclusion clause, advice, treatment or counselling must be given for the identifiable medical condition itself at the time; treatment or advice for non-specific symptoms which only later are identified as a particular disease does not ordinarily fall within the exclusion. The certificate and incorporated application were construed together and any doubt resolved against the insurer.

County Court (Birmingham) judgment for the plaintiff by Judge Boggis Q.C. (15 November 1996); reversed by a majority in the Court of Appeal (no neutral citation given in the judgment); appeal to the House of Lords [1998] UKHL 42; [1998] 1 WLR 1765.