Not upheld: premium refund entitlement dispute complaint against Cigna Europe Insurance Company SA

Decision detail

Summary

Mr B complained that Cigna Europe Insurance Company SA failed to pay him a pro-rata refund of premium after he cancelled his Cigna Global Gold private medical insurance policy. Mr B claimed the call handler led him to believe outstanding invoices needed to be submitted before cancellation, and that Cigna should have warned him that submitting claims would forfeit his refund entitlement. However, the ombudsman found that Cigna's policy terms clearly stated no refund would be paid if any claims were paid, and the call handler had clearly explained this condition. After reviewing the call recording, the ombudsman concluded Mr B understood the terms and that Cigna acted fairly in processing his claims and declining the refund when one claim was paid. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that Cigna's policy terms clearly stated no pro-rata refund would be paid if any claims had been paid during the period of cover. The call handler had clearly and fairly explained this condition to Mr B. Although Mr B claimed he was led to believe outstanding invoices needed to be submitted, the ombudsman's review of the call recording did not support this interpretation. The call handler explicitly stated that a paid claim would negate the refund entitlement. It was reasonable for Cigna to process the claims Mr B submitted in line with his request and the policy terms. Since Mr B benefitted from the cover after requesting cancellation and a claim was paid, Cigna was entitled to decline the refund.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website