Not upheld: Home insurance claim disputes complaint against Cigna Europe Insurance Company SA

Decision detail

Summary

Mr H claimed on a personal accident insurance policy for a muscle strain suffered by his wife Mrs H at work. Cigna rejected the claim, stating there was insufficient evidence that the injury was caused by an accident as defined by the policy. Mrs H's account mentioned both lifting a heavy tray and being under pressure and strain from work conditions, and her GP's records did not independently confirm an accidental cause. The ombudsman found Cigna's decision to request additional evidence was fair and reasonable, as the policy required the injury to result from an accidental, external, violent and visible cause, not from work-related pressure or strain. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that the policy required Mrs H to demonstrate a bodily injury caused by an accidental, external, violent and visible cause. The evidence provided—Mrs H's account mentioning both a lifting action and work-related pressure/strain, combined with a GP record that did not independently confirm the injury was caused by an accident—was insufficient to meet this definition. The ombudsman concluded it was reasonable for Cigna to request additional evidence to clarify whether the injury was caused by a single accidental action or by work-related pressure and strain, which would not be covered.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website