Not upheld: Travel / life insurance claim disputes complaint against Euroins AD

Decision detail

Summary

Ms C1 and Ms C2 complained that Euroins AD unfairly declined a travel insurance claim for medical treatment Ms C1 received at a private hospital after injuring her wrist on holiday. Euroins declined the claim because the policy did not cover private hospital treatment and the treatment had not been authorised. The ombudsman found that the policy terms clearly excluded such treatment, that Euroins provided reasonable guidance when Ms C1's partner contacted them, and that a clarifying email was sent explaining the policy requirements. The ombudsman accepted evidence from Euroins' Chief Medical Officer that alternative treatment options were available, and concluded that Euroins fairly declined the claim.

The Ombudsman's reasoning

The ombudsman applied the policy terms strictly and found no cover for private hospital treatment or unauthorised expenses. The ombudsman considered whether it would be fair to cover costs outside policy terms but concluded it was not appropriate given the circumstances. The ombudsman found that Euroins provided reasonable guidance during the initial call, made it clear payment could not be guaranteed, and sent a clarifying email (which the ombudsman found was most likely received based on file records). The ombudsman accepted the CMO's evidence that alternative treatment options existed, and found Euroins was prejudiced by Ms C1 not seeking authorisation before treatment.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website