Not upheld: Travel / life insurance claim disputes complaint against Cigna Europe Insurance Company SA

Decision detail

Summary

Mr S complained that Cigna Europe Insurance Company SA unreasonably declined his claim for shockwave treatment following a knee injury, while approving his physiotherapy claim. Mr S argued that because his doctor's report mentioned shockwave therapy, Cigna should have known he would undergo this treatment and either sought pre-authorisation or disclosed the exclusion earlier. The ombudsman found that Mr S's original claim on 26 November 2024 was for physiotherapy only, and Cigna's subsequent information requests were clearly limited to that claim. Although the doctor's report mentioned shockwave treatment, the ombudsman concluded it was unreasonable to expect Cigna to assume Mr S would definitely undergo this separate treatment and proactively seek pre-authorisation. The ombudsman upheld Cigna's position that the onus was on Mr S to seek pre-authorisation, and that the policy terms reasonably exclude experimental or unproven treatments. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that Mr S's original claim on 26 November 2024 was for physiotherapy only, and Cigna's subsequent information requests were clearly related to that claim. Although the doctor's report mentioned shockwave treatment, it would not be fair to conclude that Cigna should have assumed Mr S would definitely undergo shockwave therapy and proactively sought pre-authorisation. Shockwave therapy is a separate and distinct treatment from physiotherapy, and the onus was on Mr S to seek authorisation before undergoing any treatment. Had Mr S sought pre-authorisation, the treatment would have been declined at that point without him incurring costs. The policy terms exclude experimental or unproven treatments, and Cigna acted reasonably in declining the claim in line with these terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website