Not upheld: claim decline - interpretation of policy terms complaint against Society of Lloyd's

Decision detail

Summary

Mr R claimed for permanent total disablement under a personal accident insurance policy provided by Society of Lloyd's following a back injury sustained in 2010. He made the claim in 2025 after being declared totally permanently disabled. Society of Lloyd's declined the claim, stating that permanent total disablement must occur within 12 months of the accident. Mr R argued the policy only requires the accident to occasion disablement within 12 months, with permanence determinable later. The ombudsman upheld Society of Lloyd's' interpretation, finding the policy definition of bodily injury and permanent total disablement requires the disablement to occur within 12 months. Evidence showed Mr R continued working within that period, so he did not meet the policy definition. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman interpreted the policy terms to require that permanent total disablement must occur within 12 months of the accident, not merely be occasioned by the accident within that timeframe. The policy definition of 'bodily injury' requires disablement to occur within 12 months, and 'permanent total disablement' is defined as disablement lasting 12 months and beyond hope of improvement. The evidence demonstrated Mr R continued working within the 12-month period, therefore he did not meet the definition of permanent total disablement within the required timeframe. Society of Lloyd's' interpretation and application of the policy terms was reasonable.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website