Critical & Serious Illness Decision Reference 2022-0099

• Case Outcome: Rejected
• Reference: 2022-0099
• Date: 21 March 2022
• Year: 2022
• Subject Matter: Critical & Serious Illness
• Finantial Sector: Insurance
• Conducts Complained Of: Claim handling delays or issues

Decision Ref:

2022-0099

Sector:

Insurance

Product / Service:

Critical & Serious Illness

Conduct(s) complained of:

Claim handling delays or issues

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The Complainant held a private serious illness insurance policy with an insurance company (the

“Provider”).

The Complainant’s Case

The Complainant says that on the 23 July 2019 she submitted a claim to the Provider under her serious

illness insurance policy arising from her rheumatoid arthritis. The Complainant states that she was

diagnosed with this illness in October 2018 having displayed symptoms in February 2018. The

Complainant states that she still has rheumatoid arthritis but “on a more escalated level.”

Complainant states that “I have been born diagnosed with a condition that they cover.” The

Complainant states that the Provider, by letter dated 16 December 2019, refused her claim stating

that it "felt that I didn't meet their criteria definition in relation to their description of the condition one

should be in to have their claim admitted.”

The Complainant asserts that her claim should be paid and she states that "I live with chronic pain on

a daily basis and I'm on a lot of medication and injections to keep the condition at bay."

The Complainant submits that her Consultant Rheumatologist wrote to the Provider to express