Personal Accident Decision Reference 2022-0237

Case OutcomePartially upheld
Subject MatterPersonal Accident
Date20 July 2022
Finantial SectorInsurance
Conducts Complained OfMis-selling (insurance)
Decision Ref:
Product / Service:
Personal Accident
Conduct(s) complained of:
Mis-selling (insurance)
Partially upheld
The complaint concerns an accident and injury policy.
The Complainant’s Case
The Complainant took out an accident and injury policy with the Provider in 1996 and
maintained the policy “for the next 20 plus years in good faith”.
In July 2019, the Complainant sustained an injury which required surgery and a period of
convalescence. The Complainant had a [redacted] accident when he fell while repairing a
roof. He suffered full tibial plateau fracture and underwent surgery for this on 21 July 2019.
He had no use of his leg at the time and was only mobile on crutches. He says he was totally
disabled from the accident until the end of August 2019 when his “treating team advised
that he could start physiotherapy. However, he explains that he continued to be partially
disabled and required rehabilitation from his surgery for another number of weeks.
The Complainant’s representative, who became his representative in this matter, states that
a claim was submitted to the Provider on 17 September 2019, and the Provider processed
a total claim amount of €228.54 (two hundred and twenty-eight euro and fifty-four cent).
She states that the statement of benefits, which the Complainant had received on a regular
basis, had identified the accident convalescence amount on the policy to be €38.09 (thirty-
eight euro and nine cent) per day with no limit. As the Complainant's recovery occurred over
a number of weeks, and he was unable to return to work until mid-October 2019, he
expected the amount allowed under the claim to be greater.

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