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

Decision detail

Summary

Mrs S claimed on her critical illness policy with Zurich Assurance Ltd following a diagnosis of systemic lupus erythematosus (SLE). Zurich declined the claim, stating that Mrs S did not meet the specific severity criteria set out in the policy definition, which required either permanent neurological deficit or permanent kidney impairment below a GFR threshold of 30 ml/min. Mrs S complained that the term 'permanent' was not defined in the policy and was interpreted too narrowly, and that Zurich's handling was unclear and inconsistent. The ombudsman found that Zurich reasonably declined the claim as the medical evidence showed Mrs S's kidney function readings fluctuated above and below the threshold and there was no evidence of permanent neurological deficit. Although Zurich made an error in correspondence regarding figures, the ombudsman concluded the claim was fairly declined and an apology was sufficient remedy.

The Ombudsman's reasoning

The ombudsman found that Zurich reasonably declined the claim because Mrs S did not meet the specific severity criteria set out in the policy definition. Although the policy did not explicitly define 'permanent', the ombudsman concluded it was fair and reasonable to interpret it as 'long lasting and/or unchanging', consistent with dictionary definitions and industry guidance. The medical evidence showed Mrs S had some readings below the threshold but also readings above it, supporting the CMO's conclusion that her condition had not progressed sufficiently. The ombudsman noted that Zurich is entitled to set commercial criteria for claims and is not obliged to follow other clinical guidelines. The error in correspondence was acknowledged but deemed insufficient to warrant compensation given the fair decline of the claim.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website