Not upheld: Travel / life insurance claim disputes complaint against American International Group UK Limited (AIG)

Decision detail

Summary

Mr K claimed Permanent Disability benefit on his personal accident insurance following a military injury to his left foot and ankle. AIG declined the claim, stating further medical evidence was insufficient and requesting reassessment after completion of proposed treatment. Mr K provided additional evidence including an LCWRA award demonstrating total inability to work. The ombudsman found AIG acted fairly because the policy requires proof of permanent disability lasting the rest of life, and since further treatment was still being considered, improvement remained possible. The LCWRA award, while evidencing work incapacity, did not prove inability to work solely from the accident-caused injury as the policy requires.

The Ombudsman's reasoning

The ombudsman found that while Mr K's symptoms are long-standing and serious, the policy requires proof of permanent total disability lasting the rest of life. Since further treatment and surgery were still being considered, there remained a possibility of improvement, making it reasonable for AIG to await completion of the treatment plan before reassessing. The LCWRA award, while demonstrating inability to work, does not prove inability to work solely due to the accident-caused injury as required by the policy terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website