Not upheld: claim declined - outside period of insurance and outside insured perils complaint against AmTrust Specialty Limited

Decision detail

Summary

Mr B claimed on his legal expenses insurance policy for cover relating to his son's hospital treatment and subsequent detention under the Mental Health Act. AmTrust declined the claim, citing that the clinical negligence element began before the policy start date and the unlawful detention claim did not fall within the policy's insured perils. The ombudsman found the policy terms clearly limited cover to specified events within the period of insurance and to claims falling within defined insured perils. The clinical negligence claim fell outside the period of cover, and the unlawful detention claim did not fall within any listed insured peril. The ombudsman upheld AmTrust's decision and found no unreasonable delays in handling the claim.

The Ombudsman's reasoning

The ombudsman found that the policy terms clearly require claims to occur within the period of insurance and fall within specified insured perils. The clinical negligence claim related to events beginning before the policy start date, placing it outside the period of cover. The unlawful detention claim, while occurring after the policy started, does not fall within any of the insured perils listed in the policy (clinical negligence, consumer disputes, personal injury, employment disputes, property infringement, or property damage). The legal advice from specialist solicitors was properly reasoned and AmTrust was entitled to rely on it. The claim was handled without unreasonable delay given the circumstances.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website