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

Decision detail

Summary

Ms F purchased travel insurance covering medical treatment abroad and made a claim for a return journey after her initial dental treatment could not be completed due to a pre-existing sinus problem. Society of Lloyd's declined the claim, citing that it did not fall within the policy's coverage for corrective procedures. The ombudsman upheld the decline, finding that the policy only covers return journeys for medically necessary corrective procedures resulting from the original treatment, not for completing incomplete treatment. Although Society of Lloyd's provided inconsistent reasons for the decline, the ombudsman found the claim was correctly declined and no loss was caused.

The Ombudsman's reasoning

The policy terms state that cover applies when the original treatment has resulted in a medical complication requiring corrective procedures within 12 months. The ombudsman found that the sinus problem existed before treatment started and prevented completion of the original treatment. Therefore, the return journey was to complete the original treatment, not for corrective procedures, meaning the claim fell outside policy coverage.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website