Not upheld: claim rejection - failure to meet policy definition complaint against MetLife Europe d.a.c

Decision detail

Summary

Mr E held a personal accident insurance policy with MetLife and claimed benefits after injuring his knees at work. MetLife declined the claim, stating the injuries did not meet the policy definition for a ligament tear benefit. The policy required medical evidence of a complete or partial tear confirmed by radiological imaging. The ombudsman found that while Mr E suffered knee injuries with ongoing pain and treatment, the medical evidence only showed mild trauma to ligaments, not a tear meeting the policy criteria. The ombudsman upheld MetLife's decision to decline the claim as fair and reasonable, finding no evidence of unfair rejection or unreasonable delays.

The Ombudsman's reasoning

The ombudsman applied industry regulatory rules requiring insurers to handle claims promptly and fairly without unreasonably rejecting claims. The policy clearly defined the criteria for ligament tear coverage (grade 2 or 3 tear confirmed by radiological imaging). Mr E bore the burden of providing medical evidence meeting these criteria. The available medical evidence only showed mild trauma to ligaments, not a tear meeting the policy definition. MetLife's medical advisor's opinion supported this conclusion. No evidence suggested unfair rejection or unreasonable delays.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website