Partially upheld: Home insurance claim disputes complaint against Zurich Insurance Company Limited

Decision detail

Summary

Mr M suffered serious leg injuries whilst abroad and underwent surgery at a private hospital after paying €65,000 upfront. He failed to contact Zurich's 24-hour emergency helpline before treatment, instead emailing the claims team. Zurich restricted the claim to approximately £20,000 (the cost of air ambulance repatriation to the UK) on the basis that surgery could have been delayed pending repatriation. The ombudsman upheld this decision as fair and reasonable given the policy terms and Mr M's failure to notify the emergency team. However, the complaint was partially upheld because Zurich failed to proactively communicate with Mr M about the claim status after his discharge from hospital, leaving him without support for three weeks whilst anxiously awaiting confirmation of coverage for the substantial costs incurred. Zurich was directed to pay £150 compensation for this service failure.

The Ombudsman's reasoning

The ombudsman found that Zurich acted fairly in restricting the claim because: (1) the policy clearly required contacting the 24-hour emergency helpline before treatment, not emailing the claims team; (2) Mr M failed to contact Zurich Assist before surgery, preventing the medical team from advising on repatriation; (3) Zurich's medical team reasonably concluded surgery could have waited for air ambulance repatriation; (4) the lowest air ambulance quote of approximately £20,000 was a reasonable basis for limiting cover. However, Zurich failed in its duty to handle the claim fairly by not proactively keeping Mr M informed post-discharge about the status of his substantial claim, particularly during the three-week period from 23 July to 14 August 2025, causing unnecessary distress and inconvenience to a vulnerable patient.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website