Not upheld: claim rejection — application of policy exclusion complaint against AmTrust Specialty Limited

Decision detail

Summary

Miss H held an income protection insurance policy and became unemployed in June 2025 after being dismissed for gross misconduct. She made a claim on the policy and initiated employment tribunal proceedings, but AmTrust turned down her claim because the policy excluded cover for misconduct-related dismissals unless an Unemployment Tribunal found the dismissal unfair. Since no tribunal decision had yet been made, AmTrust reasonably applied the policy exclusion. The ombudsman upheld AmTrust's decision, finding the policy terms clear and fair, and noting that AmTrust appropriately offered to reconsider the claim if the tribunal found in Miss H's favour.

The Ombudsman's reasoning

The ombudsman found that the policy terms clearly and fairly excluded cover for unemployment resulting from disciplinary action for misconduct unless an Unemployment Tribunal determined the dismissal was unfair. Since Miss H's dismissal was admittedly for gross misconduct and no tribunal decision had yet been made, AmTrust reasonably relied on the policy exclusion to turn down the claim. The ombudsman noted that AmTrust appropriately offered to reconsider the claim once a tribunal judgment was reached.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website