Not upheld: claims handling - request for medical certificate and associated costs complaint against AWP P&C S.A.

Decision detail

Summary

Mr A1 complained that AWP refused to pay a travel insurance claim for medical expenses incurred while on holiday abroad without first obtaining a GP medical certificate, which would cost £500. Mr A1 also complained that he could not contact AWP while abroad. The ombudsman found that insurers are entitled to carry out reasonable investigations into claims, and requesting a medical certificate is a proportionate way to establish whether the claim relates to excluded pre-existing conditions. The ombudsman did not uphold the complaint, finding AWP's request reasonable and the £300 compensation already paid to be fair.

The Ombudsman's reasoning

The ombudsman determined that insurers are entitled to carry out reasonable investigations into claims before confirming payment. Requesting a medical certificate is a proportionate and efficient way to establish whether a claim relates to excluded pre-existing medical conditions. The policy terms entitle AWP to request information from medical records, and a GP certificate is a reasonable interpretation of this. The inability to contact AWP while abroad does not change the reasonableness of the information request. The £300 compensation already paid was considered fair for any communication failings.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website