Not upheld: Travel / life insurance claim disputes complaint against Health Shield Friendly Society Limited

Decision detail

Summary

Mr D held a Health Cash Plan with a dental benefit of £175 per benefit year. Due to Covid-19 lockdown, his dental appointment scheduled for January 2022 was rescheduled to 7 April 2022, which fell in the following policy benefit year (2022-23) rather than the unused 2021-22 year. Mr D requested Health Shield apply his claim to the 2021-22 benefit year, but Health Shield declined, citing policy terms that treat claims according to when treatment was received. The ombudsman upheld Health Shield's decision, finding the policy terms were clear, the firm was not responsible for Covid-19 disruptions, and there was no obligation to extend or defer benefits. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that Health Shield's policy terms explicitly state claims are treated according to the date treatment was received, not the date it was scheduled. Insurance policies are intended to cover uncertain events during the contract period, and insurers are entitled to retain premiums even if no claim is made. Health Shield provided cover during 2021-22 even though Mr D could not use it. The firm did not cause the appointment delay and was not responsible for Covid-19 disruptions, which were outside its control. There was no policy term allowing benefit deferral or extension. Therefore, it was fair and reasonable for Health Shield to treat the claim under the 2022-23 benefit year.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website