Not upheld: Home insurance claim disputes complaint against AWP P&C SA

Decision detail

Summary

Mr and Mrs G complained that AWP unfairly turned down claims for dental treatment costs and failed to provide clear information about policy exclusions. AWP had sent Mr G a policy certificate, Table of Benefits, and membership card with a hyperlink to the full Benefit Guide, which explicitly excluded dental prostheses from coverage. The ombudsman found that AWP's documentation clearly directed Mr G to the Benefit Guide for full terms and conditions, and that the medical evidence showed the treatment fell within the definition of dental prostheses. The complaint was not upheld as AWP provided sufficient clear information and fairly applied the policy terms.

The Ombudsman's reasoning

The ombudsman found that AWP provided clear, fair and not misleading information by sending Mr G the policy certificate and TOB with explicit references to the Benefit Guide, along with a direct hyperlink to access it online. The Benefit Guide clearly defined dental prostheses and explicitly excluded them from coverage. The ombudsman concluded that Mr G should have been reasonably aware that the TOB did not form the complete basis of cover and that he needed to check the Benefit Guide. The medical evidence confirmed that the treatment costs claimed fell within the definition of dental prostheses, which were not covered under the policy terms. Therefore, it was fair for AWP to turn down the majority of the claim.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website