Partially upheld: Motor insurance, claim handling complaint against Prudential International Assurance Plc

Decision detail

Summary

Mrs S claimed under a flexible life insurance policy with long-term care cover in July 2023. Prudential requested an occupational therapist report to clarify whether Mrs S met the policy definition of long-term disability, which was a fair approach. However, Prudential caused unnecessary delays by not promptly issuing a claim form and failing to chase medical professionals for responses, taking approximately three months for the chief medical officer to advise an occupational therapist report was needed. The delays prevented Mrs S's family from arranging professional care sooner because they did not fully understand the policy and were awaiting key documentation. The ombudsman partially upheld the complaint, directing Prudential to pay £1,000 compensation (less £500 already paid) and refund the August 2023 long-term care premium element.

The Ombudsman's reasoning

While Prudential acted fairly in requesting an occupational therapist report to clarify whether Mrs S met the policy definition of long-term disability, it caused unnecessary delays by not promptly issuing a claim form, not chasing medical professionals for responses, and taking approximately three months for the chief medical officer to advise that an occupational therapist report was needed. Had Prudential been more proactive, the claim would have been accepted many months earlier. Although the policy terms require a registered care provider to be charging for services before benefits are payable (which only occurred in February 2024), the delays prevented Mrs S's family from arranging professional care sooner because they did not fully understand the policy and were awaiting key documentation. Compensation of £1,000 fairly reflects the impact on Mrs S, and a refund of the August 2023 premium element for long-term care is appropriate given the agreed claim start date of end of July 2023.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website