Partially upheld: Travel / life insurance claim disputes complaint against The Ancient Order of Foresters Friendly Society Limited

Decision detail

Summary

Mr D claimed Permanent Total Disability benefits under his sickness and accident policy following a serious accident in 2017 that left him unable to work. Foresters declined the claim, and the ombudsman found this was fair because medical evidence did not show Mr D met the stringent policy definition requiring inability to perform six specific Activities of Daily Living irreversibly and permanently. However, the ombudsman upheld the complaint in part, awarding £150 compensation for a six-week delay in claim processing during which Foresters took no action, causing stress to Mr D during his poor health. The ombudsman noted the policy terms were clear but declined to consider the policy sale or alleged Equality Act breaches.

The Ombudsman's reasoning

The ombudsman found that the policy definition for Permanent Total Disability is stringent, requiring inability to perform six specific Activities of Daily Living irreversibly and permanently. Although Mr D cannot work, the medical evidence did not demonstrate he met this strict definition. However, Foresters was not sufficiently proactive during a six-week period when no action was taken after receiving medical evidence, causing unnecessary stress to Mr D during his poor health.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website