Not upheld: Service failures generally complaint against The Ancient Order of Foresters Friendly Society Limited

Decision detail

Summary

Ms B and Mr H complained that Foresters delayed settling a critical illness insurance claim following Mr H's heart attack and unreasonably requested additional information. Foresters argued the further information was needed to verify the policy terms were met. The ombudsman found that whilst Mr H clearly experienced a cardiac event, the policy terms required specific criteria including new characteristic electrocardiographic changes, which the initial evidence did not demonstrate. The ombudsman concluded that Foresters' request for further information was reasonable, the claim was progressed within acceptable timescales, and the complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that whilst Mr H clearly experienced a significant cardiac event, an insurer is entitled to assess claims against specific policy terms. The policy required demonstration of new characteristic electrocardiographic changes, which the initial evidence did not show. Therefore, Foresters' request for further information was reasonable and not a delaying tactic. The timescales involved were not unusual for claims of this nature and the claim was progressed reasonably throughout.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website