Not upheld: claims handling - emergency medical expenses; alleged unreasonable delays in issuing Guarantee of Payment complaint against Great Lakes Insurance UK Limited

Decision detail

Summary

Mr and Mrs M complained about Great Lakes Insurance UK Limited's handling of an emergency medical expenses claim made while Mr M was abroad on holiday. After Mr M fainted and was treated at a private hospital in Great Lakes' network, Mrs M contacted the Medical Assistance Team to arrange a Guarantee of Payment. Great Lakes requested a medical report and cost estimate from the hospital, which were provided within approximately two hours. The clinical team reviewed the report and identified a potential undisclosed pre-existing medical condition, requiring Mr M's medical records before confirming cover. Great Lakes issued a Guarantee of Payment on a disclaimer basis approximately three and a half hours after reviewing the medical report. Mrs M complained about alleged unreasonable delays and felt the firm had suggested fraud. The ombudsman found that Great Lakes handled the claim promptly and fairly, made appropriate requests for information, and did not unreasonably delay the process, and therefore did not uphold the complaint.

The Ombudsman's reasoning

The ombudsman found that Great Lakes was entitled to request a medical report and cost estimate as standard practice for medical expenses claims. The firm made Mrs M aware upfront of the information needed. The clinical team reviewed the medical report promptly (within less than two hours), and it was reasonable for Great Lakes to request Mr M's medical records to check for undisclosed pre-existing conditions given the nature of his symptoms. The firm's decision to issue a GOP on a disclaimer basis approximately three and a half hours after reviewing the medical report was pragmatic and appropriate. The ombudsman was not persuaded there were unreasonable delays, and found no persuasive medical evidence that Mr M's back pain was caused by Great Lakes' actions. Overall, the MAT handled the claim promptly and fairly, kept Mrs M informed, and treated her appropriately.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website