Not upheld: Travel / life insurance claim disputes complaint against National Deposit Friendly Society Limited

Decision detail

Summary

Mr C claimed on an accident-only income protection policy after a fall in April 2022 that resulted in a minor head injury. National Friendly rejected the claim, concluding that Mr C had not demonstrated his inability to work was caused by the accident and had not provided evidence of loss of earnings. The ombudsman upheld National Friendly's decision, finding that contemporaneous GP records showed no ongoing treatment for accident-related injuries and indicated Mr C's medical contact was primarily for pre-existing conditions including diabetes, anxiety, depression, and neuropathy. The ombudsman concluded it was reasonable for National Friendly to determine that Mr C's absence was more likely attributable to existing medical conditions rather than the accident, and that Mr C had not satisfied the policy requirement to demonstrate loss of earnings.

The Ombudsman's reasoning

The ombudsman applied the policy terms requiring that a disabling injury be directly and solely caused by the accident, and that the policyholder must be under medical care for that injury. The ombudsman examined the totality of medical evidence available when National Friendly issued its final response in March 2023. While acknowledging Mr C had a fall and received a minor head injury diagnosis, the contemporaneous GP records showed no ongoing treatment for accident-related injuries, no specialist referrals, and indicated Mr C's medical contact was primarily for pre-existing conditions. The ombudsman found it reasonable for National Friendly to conclude that Mr C's absence was more likely due to existing medical conditions rather than the accident. Additionally, Mr C failed to provide evidence of loss of earnings as required by the policy terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website