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

Decision detail

Summary

Mr H claimed on an income protection insurance policy sold by BFSL in April 2020, citing hearing loss, balance issues, dizziness and tinnitus. BFSL declined the claim, initially citing pre-existing conditions but later arguing the claim arose from lack of work availability rather than incapacity. The ombudsman found the hearing loss was not pre-existing but upheld BFSL's decision because Mr H provided insufficient medical evidence to demonstrate he met the policy's definition of 'incapacity' (total inability to carry out his occupation). The timing was significant: Mr H continued working despite hearing issues from December 2023 and only took sick leave after receiving employment termination notice. The complaint was not upheld and no remedy was ordered.

The Ombudsman's reasoning

The ombudsman applied the policy definition of 'incapacity' requiring Mr H to demonstrate he was totally unable to carry out his occupation due to illness. While accepting the hearing loss was not pre-existing and therefore not excluded, the ombudsman found the medical evidence did not demonstrate Mr H met the incapacity threshold throughout the deferred period and beyond. The timing was significant: Mr H continued working despite hearing issues from December 2023, and only took sick leave after receiving employment termination notice in February 2024. The medical evidence showed hearing decline but not total inability to work for any employer. The ombudsman noted insurance policies provide benefits only when specific criteria are met, not for all situations of illness.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website