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

Decision detail

Summary

Mr B held an income protection insurance policy with British Friendly that contained an exclusion for left hip-related conditions. He claimed on the policy for left hip pain preventing him from working, which was declined due to the exclusion. Mr B then argued his shoulder pain was also preventing work, but British Friendly declined this too after seeking medical evidence. The ombudsman found the decline was fair because medical records showed Mr B was signed off work in August 2023 for hip pain, the shoulder condition was not documented as a work-preventing issue until October 2023, and the consultant letter lacked specific detail on how the shoulder impacted work ability.

The Ombudsman's reasoning

The ombudsman concluded that British Friendly fairly applied the left hip exclusion to the initial claim. When Mr B claimed shoulder pain was also preventing work, British Friendly reasonably sought medical evidence. The medical evidence showed Mr B was signed off work in August 2023 due to hip pain, but the shoulder condition was not documented as a reason for work absence until October 2023, after the claim had been declined. The consultant letter lacked specific detail on how the shoulder condition impacted work ability. Therefore, British Friendly reasonably concluded the policy definition of incapacity was not clearly demonstrated.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website