Not upheld: Travel / life insurance claim disputes complaint against The Ancient Order of Foresters Friendly Society Limited

Decision detail

Summary

Mrs M claimed under critical illness cover provided through her employer by Foresters following a work injury in May 2017 that resulted in persistent concussional symptoms (mild traumatic brain injury). Her initial claim for 'prolonged concussion symptoms' was declined, and a subsequent request for review under the covered condition of 'traumatic head injury' was also declined. Foresters cited two reasons: no direct head trauma occurred (evidence suggested whiplash-type mechanism), and the policy definition requiring 'death of brain tissue' was not met as clinical examinations and imaging showed no abnormalities. The ombudsman upheld Foresters' decision, finding that Mrs M's condition fell outside the policy coverage on both grounds, despite acknowledging her genuine and permanent symptoms that significantly impact her daily life.

The Ombudsman's reasoning

The ombudsman found that Mrs M's claim fell outside the policy coverage on two grounds. First, her condition did not arise from a traumatic head injury as defined in the policy - the evidence suggested a whiplash-type mechanism rather than direct head trauma. Second, even if traumatic head injury were established, Mrs M did not meet the specific policy definition requiring 'death of brain tissue due to traumatic injury resulting in permanent neurological deficit with persisting clinical symptoms' because clinical examinations and imaging showed no objective evidence of brain tissue death. While the ombudsman acknowledged Mrs M's symptoms are real and impact her daily life, the absence of objective clinical or radiological evidence of brain tissue death meant the policy condition was not met. The ombudsman noted that Foresters is entitled to determine the terms under which it covers conditions and to rely on those terms when assessing claims, and that it is for the claimant to demonstrate they meet a policy term.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website