Upheld: Travel / life insurance claim disputes complaint against ARAG Legal Expenses Insurance Company Limited

Decision detail

Summary

Mr H claimed on a legal expenses insurance policy for assistance with a clinical negligence claim relating to alleged negligent treatment of prostatitis and resulting conditions. ARAG declined the claim, citing that part of the alleged negligence occurred before the policy was taken out and that exclusions for diagnostic failures applied. The ombudsman found that while most of the claim flows from events before the policy start date (April 2022) and therefore lacks coverage, ARAG should have separately considered the claim relating to anal fissures allegedly caused by the failure to refer for pelvic health physical therapy, as this represented an intervening act. The ombudsman upheld the complaint and directed ARAG to reconsider the anal fissure aspect of the claim and pay £200 compensation for service failures.

The Ombudsman's reasoning

The ombudsman found that most of Mr H's claim flows from the initial event in April 2022 (before the policy started on 6 October 2022) and therefore falls outside coverage. However, the alleged negligence regarding the failure to refer for pelvic health physical therapy, which allegedly caused the anal fissures, was identified as a separate intervening act that does not foreseeably flow from the first event. This aspect should be reconsidered by ARAG to determine if it meets the remaining policy terms and conditions. The ombudsman also found ARAG failed to deal with some communications within service standards.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website