Not upheld: claim declined - insufficient evidence and costs below excess complaint against Great Lakes Insurance SE

Decision detail

Summary

Mr H claimed on a travel insurance policy for medical expenses and loss of holiday following an ankle injury sustained abroad on 2 June 2025. Great Lakes declined the claim citing insufficient evidence of loss of holiday and costs below the excess threshold. The ombudsman found the decline reasonable: medical and taxi costs totalling £94 fell below the £95 excess for Section 1, the £25 excursion cost fell below the £95 excess for Section 3, and the loss of holiday claim lacked the required evidence of confinement to room on explicit doctor's orders. Although Mr H provided photos and hospital attendance evidence, he did not provide a medical certificate ordering confinement, only advice to rest for 48-72 hours. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman applied the FCA's ICOBS requirement that insurers handle claims promptly and fairly without unreasonably declining claims, but noted that insurers are entitled to rely on policy terms and the evidence provided. For the medical expenses claim (£94 total), this fell below the £95 excess applicable to Section 1, so the decline was reasonable. For the loss of holiday claim, the policy definition explicitly requires confinement to a room on the orders of a treating Medical Practitioner. Mr H only provided evidence of advice to rest for 48-72 hours, which falls short of an explicit order to remain confined. The ombudsman rejected the argument that common sense dictates bed-boundness from a twisted ankle, noting that limited mobility does not necessarily prevent leaving the room. The onus was on Mr H to provide sufficient evidence, not on Great Lakes to chase gaps in evidence. The ombudsman was not persuaded by Mr H's unsupported claim that Great Lakes had offered to obtain evidence from third parties.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website