09/10/2025
NONDECLARATION OF FAMILY HISTORY -
⚖️ 1️⃣ Duty of Disclosure (Utmost Good Faith / Uberrimae Fidei)
Sa insurance, may legal principle called utmost good faith — meaning both parties, lalo na ang insured (client), must declare all material facts truthfully and completely.
👉 “Material fact” = anumang impormasyon na makakaapekto sa decision ng insurance company kung tatanggapin ba nila ang application at anong premium ang dapat.
Example: family history of cancer, heart disease, etc. — very material ito sa life insurance.
⚖️ 2️⃣ What Happens If Not Declared?
If later on, nalaman ng insurer (halimbawa, sa claim investigation) na hindi dineclare ng client ang existing medical condition or family history, maaari nilang i-deny ang claim on the ground of misrepresentation or concealment.
Even if approved na ang policy, kung mapatunayan na may non-disclosure of material fact, may karapatan ang insurer na:
Ivoid o icancel ang policy, or
Ideny ang claim if within the contestability period (usually 2 years from issue date).
⚖️ 3️⃣ Contestability Period
Sa ilalim ng Insurance Code of the Philippines, meron tayong tinatawag na 2-year contestability clause.
➡️ Within 2 years, puwedeng i-contest ng insurer ang policy kung may misrepresentation or concealment.
➡️ After 2 years (kapag policy is in force and premiums are paid), it becomes incontestable, except for cases of fraud.
CONTESTABILITY PERIOD -
⚖️ 1️⃣ After the Contestability Period (2 years)
Kapag lampas na sa 2 years mula sa policy issue date or latest reinstatement date, at regularly paid ang premiums —
➡️ the policy becomes “incontestable” under Section 48 of the Insurance Code of the Philippines.
👉 Meaning: the insurance company can no longer deny a claim just because of unintentional misrepresentation or non-disclosure of facts (like family history), as long as there was no fraud or intentional deceit.
⚖️ 2️⃣ However — Fraud Is an Exception
Kung mapatunayan ng insurer na sinadya o fraudulent ang hindi pagdeklara (for example, tinago talaga ng client na may cancer history siya o may existing condition na alam niya),
➡️ the insurer can still deny the claim, even after the 2-year period.
Ang keyword po dito ay intent to defraud.
If the omission was honest or unintentional, and the policy has passed the 2-year contestability clause, then the insurer must pay the claim.
✅ 3️⃣ Example Situation
Policy issued: January 2020
Regularly paid, no lapses
Claim filed: April 2025
➡️ Since more than 2 years na, the policy is incontestable — PRU Life UK generally cannot deny the claim based on non-disclosure of family medical history unless there is clear proof of fraud.
FAUD -
⚖️ 1️⃣ Paano nalalaman kung may “fraud” o sinadya ang hindi pagdeklara?
Sa insurance, fraud = may intent to deceive.
Hindi lang simpleng nakalimutan — kailangan may patunay na tinago nang sinadya ang impormasyon na alam ng insured na makakaapekto sa approval ng policy.
Para mapatunayan ito, nag-iimbestiga ang insurance company kapag may claim (lalo na death or critical illness).
🔍 2️⃣ Paano sila nag-iimbestiga
Usually, ginagawa ito ng Claims Investigation Unit (CIU) o Underwriting Review Team ng insurer.
Narito ang mga sources of information na ginagamit nila:
✅ Medical Records – hospital records, lab results, doctor’s notes, health declarations, PhilHealth records, etc.
✅ Death Certificate / Attending Physician’s Report – nakikita dito kung gaano katagal na ang sakit.
✅ Interviews with family / attending physician – minsan tinatanong kung alam ba ni insured ang sakit bago nag-apply.
✅ Application form vs. actual findings – tinitingnan kung may malaking discrepancy (e.g., “No” sa history of cancer, pero later found out nagpa-biopsy 1 year before application).
⚠️ 3️⃣ Halimbawa ng Fraud (Intentional Concealment):
Sinabi sa application “No family history of cancer,” pero may supporting documents (like hospital or insurance records) showing parent died of cancer a few years before.
May existing diagnosis (e.g., diabetes, hypertension) before application pero tinago intentionally para makakuha ng standard rate.
Gumamit ng ibang name, date of birth, o maling health information.
👉 In these cases, fraudulent intent ang basehan — ibig sabihin, alam ng insured ang truth pero sinadya niyang itago.
💡 4️⃣ Kapag walang proof of intent
Kung wala silang makitang malinaw na ebidensya na sinadya — halimbawa, hindi naman alam ng insured na may cancer na pala siya, or simpleng nakalimutan na may ganung family history —
➡️ hindi considered fraud, lalo na kung lagpas na sa 2-year contestability period.
In this case, the insurer must honor the claim.
✅ In short:
Fraud = may intent + may proof.
Kung wala pareho, the insurer cannot deny the claim, lalo na kung matagal na ang policy at tuloy-tuloy ang bayad.
INVESTIGATION AFTER CONTESTABILITY PERIOD -
⚖️ 1️⃣ Oo, pwede pa rin silang mag-investigate — pero may limit.
👉 Investigation and Contesting are two different things.
Investigation = pag-verify ng facts bago magbayad ng claim (normal process).
Contesting = pag-deny ng claim dahil sa misrepresentation or concealment.
So kahit lagpas na ng 2 years, pwede pa rin mag-investigate ang insurer to verify validity ng claim (standard process).
Pero — hindi na nila pwedeng gamitin ang simpleng misrepresentation bilang reason to deny unless may fraud.
⚖️ 2️⃣ Ang batas na basehan: Section 48, Insurance Code of the Philippines
“After a policy of life insurance made payable on the death of the insured shall have been in force during the lifetime of the insured for a period of two years... it shall be incontestable on the ground of misrepresentation or concealment, except for fraud.”
📌 Meaning:
✅ Yes, they can still investigate.
❌ But they can’t deny the claim just because may nakitang omission — unless mapatunayan nilang fraudulent talaga.
🔍 3️⃣ Bakit kailangan pa rin mag-investigate kahit incontestable na?
Because the insurance company must still:
Confirm na valid ang cause of death/claim;
Verify kung covered sa policy ang event;
Check kung walang fraud o foul play;
Process legal documents like proof of death, beneficiaries, etc.
So yes, part pa rin ito ng standard due diligence — pero limited na ang reason para mag-deny.
⚠️ 4️⃣ Example Situation
Policy issued: March 2020
Regularly paid premiums
Death claim filed: May 2025
➡️ The insurer can review hospital records, doctor’s report, etc.
➡️ Pero hindi na nila puwedeng i-contest based on “non-disclosure” ng family history, unless may clear proof of fraud (e.g., fake medical certificate, deliberate lying).
