Not upheld: Travel / life insurance claim disputes complaint against Zurich Assurance Ltd

Decision detail

Summary

Mr K held a critical illness insurance policy with Zurich that would pay a claim for aorta surgery if the surgery took place before the policy end date of 31 August 2025. When Mr K contacted Zurich in 2025 about making a claim, he did not have a confirmed surgery date. Zurich explained that the policy would only pay if the surgery occurred before the end date. Mr K complained, claiming he had been reassured in earlier telephone calls that the timing was irrelevant, but these calls were no longer available. The ombudsman found the complaint not upheld, determining that the policy terms were clear and Mr K had not met the definition of the cover by undergoing the surgery before the policy end date.

The Ombudsman's reasoning

The ombudsman applied the starting point that the policy terms and conditions form the contract between the parties. The policy explicitly states that critical illness cover is only paid when the relevant definition is met, which requires the surgery to have been undergone. Since Mr K had not undergone the surgery before the policy end date, he could not demonstrate he met the definition. The ombudsman found Zurich's response was not unreasonable and consistent with the policy terms. Regarding the alleged telephone reassurances, the ombudsman noted these were not properly investigated, no recordings were available, and the written advice from Zurich in August 2025 was consistent with the policy terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website