Travel Decision Reference 2022-0296

• Case Outcome: Rejected
• Subject Matter: Travel
• Reference: 2022-0296
• Date: 30 August 2022
• Finantial Sector: Insurance
• Conducts Complained Of: Rejection of claim,Rejection of claim - late notification

Decision Ref:

2022-0296

Sector:

Insurance

Product / Service:

Travel

Conduct(s) complained of:

Rejection of claim

Rejection of claim - late notification

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The complaint arises following what the Complainant has said was the failure by

orthopaedic doctors in the United States, to accept her travel insurance policy as adequate

insurance cover, after she sustained a wrist injury. Another issue arises from the Provider

declining her “Personal Accident” insurance claim under the Policy.

The Complainant’s Case

The Policy was incepted by the Complainant on 18 January 2018. She travelled to the

United States and was covered for the period 06 February 2018 to 27 April 2018.

Whilst in the United States, the Complainant had an accident on 25 February 2018

suffering an injury to her wrist. The Complainant contacted the Provider’s emergency

assistance service, approximately 2 weeks later, on 13 March 2018 to notify it of her

injury.

On 15 March 2018 the Provider’s emergency assistance service provided authorisation to

the hospital in the USA for the Complainant to have surgery on 16 March 2018 and

confirmed that the surgery would be covered under the Policy.

The surgery was postponed until the 23 March 2018 due to the Complainant falling ill, and

the Provider’s emergency assistance service again confirmed and authorised the surgery

scheduled for the 23 March 2018, as covered under the Policy.

- 2 -

/Cont’d…

The Complainant never underwent the surgery. The Complainant submits that the Policy

was not accepted by the orthopaedic doctors at the relevant hospital in the United States.

The Complainant submits in her complaint to this Office on 01 April 2019 that:-

“Now after a long time of back-and-forth correspondence with [the Provider], they

are still insisting that they were not in the wrong by not being there for me and that

their / my travel insurance was not accepted by all 7 Orthopaedic Doctors in the

Napa Valley / California. They have not taken my claim seriously at all and have

avoided from the start of my claim to explain why in their policy it does not say “we

cannot be held responsible for a doctor / doctors refuse our Travel Insurance. Which

is exactly what happened to me much to my shock, surprise and disappointment

which has left me with a permanently disabled left wrist.”

Further the Complainant states on 01 April 2019:-

“I must also tell you that I have taken out [Provider] insurance twice a year for quite

some years now and have always read my travel Insurance Cover details and have

always felt safe and have had faith in them until now, my very first time I needed

them, it didn’t work. This – my first claim and letter. I don’t want to go on and on

and I have written so many letters since May 2018.”

In referencing all of the medical reports and medical information the Complainant

submits:-

“The Provider by law has to give you my file with photos and all the correspondence

all the letters and emails I sent it, and all the letters and emails that it sent me –

including an email and report from my GP [GP’s name] a report from [doctor’s

name] who the Provider made me go and see and who took three months to send

[the Provider] his report and the report from NHS Orthopaedic [name redacted]

from [hospital name redacted].”

In explaining the impact this dispute with the Provider has had on the Complainant, she

submits:-

“The only reason I have been going to California twice a year since 2011 is to look

after and spend time with my mother and father whom I love very much. My dad

unfortunately died in 2014 but I have kept going to spend time with and look after

my mother twice a year. Due to [the Provider] I was unable to see my mother the

second time last year because they have kept me waiting for responses from them

from the report from my GP. Then had to wait to see their Independent Orthopaedic

[doctor’s name] who I saw in September last year – it was booked for October but I

called them and was lucky to bring forward to September and then he took 3

months to send them his report – keeping me waiting again. Then I had to see my

GP again to be referred to an Orthopaedic Consultant at [hospital name] which took

4 weeks – waiting again – and all along I knew it was too late for an operation

because the self-healing of my wrist was very far gone and it was no more an

emergency.”