Upheld: Travel / life insurance claim disputes complaint against National Deposit Friendly Society Limited

Decision detail

Summary

Mrs J claimed £403.80 for dental treatment including a 3D scan. National Friendly paid £303.80 but declined to cover the £100 3D scan, claiming it was an x-ray not covered by the policy. The dispute centred on whether National Friendly should apply a 2011 addendum limiting dental cover to eight treatments, or the 2015 policy document stating coverage for any non-cosmetic dental treatment. The ombudsman found the 2015 policy document was the legally binding terms and should have been updated if National Friendly intended to apply the addendum. Since the 3D scan was a diagnostic test necessary for wisdom tooth extraction (non-cosmetic), it was covered under the 2015 policy terms. The ombudsman upheld the complaint and required reimbursement of £100 plus interest.

The Ombudsman's reasoning

The ombudsman found that the latest policy document issued to Mrs J in March 2015 was the legally binding terms and conditions, as it stated it formed the complete guide along with the application. The 2011 addendum should not have been applied to claims after the new policy document was issued without the policy document being updated to reflect those terms. The 3D scan was a diagnostic test (as defined in the policy) necessary for medical purposes (wisdom tooth extraction) and therefore constituted non-cosmetic dental treatment covered under the policy terms. National Friendly's own confusion about which terms applied, combined with the ambiguity in the dentist's statement of account regarding the hygienist cost, meant it was unreasonable to expect Mrs J to remember which policy terms applied. As National Friendly drafted the policy terms, any ambiguity should be interpreted in Mrs J's favour.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website