Upheld: Home insurance claim disputes complaint against Health Shield Friendly Society Limited

Decision detail

Summary

Mrs P and Mr P held a health cash plan with Health Shield that provided worldwide cover for trips of no more than 28 days. While on a trip booked for longer than 28 days (30 July to 11 September 2025), Mrs P was hospitalised for eight nights starting 18 August 2025 with acute gastroenteritis. Health Shield declined the claim citing the trip duration exceeded the 28-day limit. The ombudsman upheld the complaint, finding it fair and reasonable to settle the claim because the hospitalisation occurred within the first 28 days of the trip and was unrelated to the trip duration exceeding the policy limit.

The Ombudsman's reasoning

Although the policy terms strictly limit worldwide cover to trips of no more than 28 days, the ombudsman found it would not be fair and reasonable to decline the claim because: (1) the hospitalisation occurred within the first 28 days of the trip; (2) the medical incident (acute gastroenteritis) was unrelated to the trip duration; and (3) Health Shield was not disadvantaged by the trip exceeding the maximum duration given the incident occurred within the normally covered period. The ombudsman concluded it would be unfair to decline the claim based on breach of a policy condition when the cause of the claim was not connected to that condition.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website