Not upheld: Travel / life insurance claim disputes complaint against Prudential Assurance Company Limited

Decision detail

Summary

Mr A claimed on his life and serious injury policy with Prudential after suffering an ankle injury that prevented him from working. Prudential assessed the claim under the total permanent disability section using a Functional Activity Tests basis as specified in the policy terms. Although Mr A's GP indicated he could not complete two of the six required work tasks, Prudential declined the claim because the medical evidence did not demonstrate the disability would be permanent. The ombudsman upheld Prudential's decision as fair and reasonable, finding the FATs assessment basis was clearly stated in the policy schedule. The ombudsman directed Prudential to pay £200 compensation for delay in communicating the decision and noted that Prudential should review the claim if Mr A provides new evidence of permanent disability.

The Ombudsman's reasoning

The ombudsman found that Prudential fairly assessed the claim on a FATs basis as specified in the policy terms. While the GP questionnaire confirmed Mr A's inability to perform two tasks at the time of assessment, the policy definition requires that the disability be permanent with no prospect of improvement. The available medical evidence did not demonstrate permanence, making Prudential's decline decision reasonable. The ombudsman also noted that any complaint about mis-selling or incorrect information at the point of sale should be directed to the policy seller, not Prudential.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website