Upheld: unfair claim decline and poor claims handling complaint against CIGNA Life Insurance Company of Europe SA-NV

Decision detail

Summary

Mr G claimed on his international medical insurance policy after sustaining injuries while in hospital. CIGNA declined the claim citing general exclusion 29 for hazardous sporting activities (surfing), based on one medical report mentioning surfing. However, the ambulance report—the first record of the injury cause—referred only to Mr G falling on the beach with no mention of surfing, and CIGNA had previously received this report. After Mr G complained to the FOS, CIGNA accepted it should not have relied on the exclusion. The ombudsman upheld the complaint, finding CIGNA's decision was unreasonable and caused significant distress to Mr G, who was vulnerable and in an unfamiliar country. The ombudsman directed CIGNA to reassess the claim without applying the exclusion and pay £1,300 compensation for distress and inconvenience.

The Ombudsman's reasoning

The ombudsman found that CIGNA had an obligation to handle claims fairly and promptly and should not unreasonably decline claims. Although there was initially inconsistent information about how the injury occurred, CIGNA should have properly considered the ambulance report (the first and most reliable record) which made no reference to surfing. On the balance of probabilities, had CIGNA properly considered this information, it would have agreed to cover the medical costs. The ombudsman was satisfied that CIGNA's unreasonable decision to decline the claim led to Mr G's treatment being stopped and early discharge while he was vulnerable and recovering from a serious injury in an unfamiliar country. This caused unnecessary distress, worry, inconvenience, and plausibly resulted in being chased for outstanding medical costs. CIGNA had multiple opportunities to correct its error but maintained its position.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website