Not upheld: claim rejection - policy definition dispute complaint against AMERICAN INTERNATIONAL GROUP UK LIMITED (AIG)

Decision detail

Summary

Mr B claimed on a personal accident policy after suffering a tendon injury while playing recreational sport by pushing off his leg. AIG rejected the claim, arguing it did not meet the policy definition of accident as an 'event that's sudden and unexpected', since pushing off one's leg is a foreseeable action during the sport. Although AIG acknowledged poor claims handling and paid £75 compensation plus reimbursement of medical costs, Mr B complained to the FOS. The ombudsman upheld AIG's decision, finding that while the injury was unexpected, the causative event (pushing off) was foreseeable and therefore did not meet the policy definition of accident.

The Ombudsman's reasoning

The ombudsman applied regulatory rules requiring insurers to handle claims promptly and fairly without turning down claims unreasonably. The key issue was whether the injury met the policy definition of accident as 'an event that's sudden and unexpected'. While the injury itself was sudden and unexpected to Mr B, the ombudsman found that the event causing the injury (pushing off one's leg) was a foreseeable and expected action during the sport. Therefore, the event did not meet the policy definition of accident, making AIG's decision to reject the claim reasonable and fair.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website