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ombudsman news

issue 123

January/February 2015

travel insurance - winter sports

Because of the range of holiday types and destinations, travel insurance policies are also wide-ranging. Winter sports cover is generally offered as an optional extra - recognising the generally riskier nature of the activities involved.

But even if someone’s paid extra for a specific sort of cover, they’re still unlikely to be covered in every situation. Like the “standard” sections of an insurance policy, any winter sports “add on” will be subject to limitations and exclusions. And inevitably, this “small print” is at the centre of most of the complaints that reach us.

If their claim is rejected, consumers often tell us that they weren’t told about the particular exclusion that the insurer is relying on - for example, liability for damage to hired sports equipment.

In these cases, we’ll look into how the policy was sold - and what information was available to the consumer. If we find the information wasn’t clear enough, we’ll consider whether this had an impact on what the consumer did next.

In other cases, consumers don’t necessarily think that their policy was mis-sold - but disagree with the insurer’s decision that a certain exclusion should apply. For example, where a claim for medical fees has been made under winter sports cover, an insurer might say that someone should have chosen a public hospital, rather than a private one.

But - like any other type of insurance - a strict application of an exclusion can result in an unfair outcome. So we’ll always look at the particular circumstances of what happened - including the urgency of the treatment, and what options were available to the consumer.

If we decide that a claim should be paid - because a policy was mis-sold or because an exclusion was unfairly applied - we’ll tell the business responsible to put things right. This generally means paying the claim - adding interest - in line with the other policy terms.

index of case studies

  • 123/1 - consumer complains that medical claim has been rejected - because travel insurance doesn’t have winter sports cover
  • 123/2 - consumer complains that travel insurer won't pay medical claim - as she wasn't covered for travel to the USA
  • 123/3 - consumer complains that insurer has rejected claim for private medical fees after breaking leg on skiing holiday
  • 123/4 - consumer complains that travel insurance claim has been rejected - because policy excludes use of motorised vehicles
  • 123/5 - consumer complains that travel insurer has rejected claim for cancelled course fees and flights
  • 123/6 - consumer complains that insurer has rejected claim for UK medical costs - after skiing accident abroad

123/1
consumer complains that medical claim has been rejected - because travel insurance doesn’t have winter sports cover

Mr and Mrs A’s home insurance was up for renewal. They’d heard their bank offered a packaged account that included home insurance, so they had a meeting in their local branch with an adviser.

When the adviser explained more about the home insurance that the account offered, Mr and Mrs A thought that it would cover everything they needed it to. They also thought the travel insurance that came with the account sounded like a good deal, as they took out a policy every year anyway. So they decided to take out the account.

When Mr and Mrs A went skiing later that year, Mr A had an accident - and needed treatment in hospital. But when the couple called the insurer to make a claim for Mr A’s medical expenses, it was turned down. The insurer said that winter sports cover was an optional extra - which Mr and Mrs A didn’t have.

Mr and Mrs A complained to the bank - saying that they were sure their policy included winter sports. But the bank said that it would have been clear when they took out the bank account that the winter sports cover cost extra. Frustrated, Mr and Mrs A contacted us.

complaint upheld

We needed to decide whether the bank had made sure the insurance was right for Mr and Mrs A. We also needed to know whether the bank had given Mr and Mrs A clear information about the account and its benefits.

We asked the bank for the records they had from the meeting between Mr and Mrs A and the adviser. The bank said that their adviser couldn’t remember the details - but the brief customer notes we were sent showed that Mr and Mrs A had said that they went on holiday three times a year. So it was clear that their holiday habits had been discussed.

Mr and Mrs A told us they wouldn’t risk skiing without cover. They said that they remembered the adviser telling them winter sports would be covered when they mentioned that they went skiing in France every year. They also showed us that their old travel insurance policy had winter sports cover. So it seemed likely to us that this was a feature they’d have wanted.

The bank said they’d sent Mr and Mrs A a welcome pack which said that the winter sports cover was optional. But they weren’t given the pack in the meeting - it was sent a couple of months later. In our view, Mr and Mrs A should have been able to rely on the information they were given in the meeting - without needing to go through detailed documents at a much later date, after they’d already made their decision.

Based on Mr and Mrs A’s history of buying insurance, we didn’t think they would have gone skiing without it. We thought they would have still taken out the packaged account if they’d known the winter sports cover was extra - as both the home and travel insurance were potentially useful to them. And we thought they would have paid extra for the winter sports cover.

In all the circumstances, we decided that the bank hadn’t given Mr and Mrs A clear information about the travel insurance policy included with the packaged bank account.

We told the bank to pay the claim - adding 8% interest, but deducting the cost of the extra winter sports cover that Mr and Mrs A would have bought if the information had been clear.

123/2
consumer complains that travel insurer won’t pay medical claim - as she wasn’t covered for travel to the USA

On her second day skiing in the USA, Mrs R fell on the slopes and fractured her ankle. After a discussion with a local doctor, she had surgery at a hospital near to the ski resort.

A week later, when she was back in the UK, Mrs R contacted her travel insurer to claim back her medical costs. But the insurer refused to pay out - saying that they hadn’t authorised the surgery.

Mrs R was confused. She explained that the hospital had told her that they’d contacted the insurer - and as the surgery had gone ahead, she’d assumed it had been authorised. The insurer agreed to review Mrs R’s file - but in doing so, they found that her policy didn’t cover the USA anyway.

At this point, Mrs R made a complaint. She told the insurer that she had several trips planned for that year - and was sure she’d taken out a policy that covered everything she’d planned to do. She said that if she’d known her operation wasn’t covered, she would have returned to the UK to have it - and wouldn’t have run up the medical costs.

However, when the insurer wouldn’t change their mind, Mrs R asked for our help.

complaint upheld

We asked Mrs R how she’d taken out the policy - so we could better understand why she was saying she thought she was covered for travelling to the USA. She explained that she’d bought the policy on the insurer’s website - and thought she’d ticked the right boxes to add “worldwide” and “winter sports” cover.

Mrs R sent us the confirmation email she’d received after buying the policy. In very small print, towards the bottom of the email, it said: “Destination: 24/7 Worldwide Exc USA/Can/Caribbean - AMT[annual multi-trip].

We accepted that, on the face of it, the email said that travel to the USA wasn’t covered. But we didn’t think this information - full of abbreviations and acronyms - was clear enough. In our view, if it had been, Mrs R would have realised that she hadn’t bought the cover she wanted. The fact she’d added winter sports cover strongly suggested that she’d intended to take out the right level of cover.

It seemed to us that there had just been a misunderstanding. If Mrs R had been given clearer information in the email - and noticed her mistake - the insurer could have quickly put things right by charging her the extra premium.

However, the insurer was also saying that they hadn’t authorised the surgery - and wouldn’t have paid for it anyway. So we needed to establish what Mrs R knew about this - and why she’d decided to go ahead.

We asked Mrs R what she remembered about what had happened. She explained that she’d been told by a local doctor that she could return home with a cast and be treated in the UK - or have the fracture “pinned” in the US before she left. She said the hospital had told her they’d contacted the insurer, which she thought meant it had been authorised.

We contacted the hospital and asked for their records of the conversations they’d had with the insurer. They told us that they didn’t have recordings of any phone calls - but they sent us call notes made by the doctor who’d seen Mrs R.

The notes indicated that, after the first call to the insurer, the doctor had understood that the surgery had been authorised. They also showed that, in a second conversation, the doctor and the insurer had discussed the fees.

We didn’t think the fees would have been discussed if the insurer hadn’t said that Mrs R’s operation had been authorised. We also didn’t think the hospital would have treated Mrs R if they’d had concerns that the insurer wouldn’t pay them.

In our view, the evidence strongly suggested that that the hospital had believed that the insurer had authorised Mrs R’s surgery - and that she had gone ahead on that basis. Mrs R had been given the option of returning home - where she would have been treated for free. We didn’t think she would have had the surgery in the USA if she’d known she wasn’t covered.

In all the circumstances, we decided the insurer had unfairly rejected Mrs R’s claim. We told them to pay it as if she’d bought the right level of cover - adding 8% interest.

123/3
consumer complains that insurer has rejected claim for private medical fees after breaking leg on skiing holiday

While Mr and Mrs J were skiing in Italy, Mrs J fell and broke her leg - and was admitted to the local state hospital.

The doctor assessing Mrs J told her that she’d need an operation as soon as possible. Because the hospital had a long waiting list, and was running a reduced service over the Easter holidays, he recommended that she be transferred to a private hospital.

While Mrs J was being seen by the doctor, Mr J phoned their travel insurer to tell them what had happened - and to check what treatment would be covered by the policy. The person he spoke to said that they couldn’t say - because claims would only be dealt with once the insurer had received the medical records.

Based on the doctor’s advice, Mrs J decided to go to a local private hospital for surgery - and Mr J arranged for the hospital to email the doctor’s records to the insurer. By the time the insurer emailed back to say they weren’t prepared to pay - because they didn’t cover private treatment - the surgery was already underway.

Mr J paid Mrs J’s medical fees on a credit card. But once they were back in the UK, the couple complained to the insurer. They explained that they would have had the treatment on the Italian state health system. But they’d been told that the treatment was urgent - and they’d been very worried about the consequences of delaying it.

However, the insurer wouldn’t change their position - and Mr and Mrs J contacted us.

complaint upheld

The insurer told us that Mr and Mrs J’s policy clearly excluded private medical treatment. They said that they expected their customers to take a European Health Insurance Card (EHIC) - allowing them to get lower-cost or free treatment - and to use public hospitals.

We asked the insurer for a copy of the terms and conditions of Mr and Mrs J’s policy booklet. The section they were using to turn down the claim was “Reciprocal Health Care Agreements”, which said:

“If you are travelling to countries within the European Union (except for the UK), we strongly recommend you take an EHIC card and make sure that any medical treatment is provided at hospitals or by doctors working within the terms of the reciprocal healthcare agreement. If you are admitted to a private clinic you may be transferred to a public hospital as soon as the transfer can be arranged safely.”

In other circumstances, this wording might have meant that a claim for private medical fees wasn’t covered. However, we didn’t think Mr and Mrs J’s situation was as clear cut as the insurer was saying.

Mr and Mrs J gave us a copy of Mrs J’s medical records, which they’d asked the hospital to send them. These confirmed that the doctor had advised Mrs J that she needed treatment urgently. According to the records, she would otherwise be at risk of deep-vein thrombosis and long-term damage to her leg.

The records also confirmed that the doctor had recommended that, because of the Easter holidays, the only way Mrs J could have the surgery within the next week was if she went to a private hospital.

Mr and Mrs J told us that they had EHIC cards. We didn’t think there was any reason to doubt - if the situation had been different - that Mrs J would have had treatment on the Italian state system. But given the advice she had received about the risks of delaying the surgery, we could understand why she’d decided to use a private hospital.

The insurer told us that, in their view, if the surgery had really been urgent, the state hospital could have treated Mrs J sooner. But they couldn’t provide any medical evidence to show that that the surgery wasn’t urgent. And in our view - in a hospital away from home and under a lot of stress - Mr and Mrs J hadn’t been in a position to question the doctor’s assessment.

In all the circumstances, we decided that the insurer had unfairly turned down Mr and Mrs J’s claim. We told them to pay Mrs J’s medical fees - adding 8% interest.

123/4
consumer complains that travel insurance claim has been rejected - because policy excludes use of motorised vehicles

While Mr K was skiing in Canada, he took a few days off to try some other activities. On the second day, he rented a snowmobile - but lost control and collided with a tree. Although Mr K wasn’t badly hurt, the snowmobile was damaged - and he had to pay the rental company for the repairs.

A few days later - once he was back in the UK - Mr K phoned his travel insurer to explain what had happened. But the person on the insurer’s helpline said that while Mr K’s policy covered some “personal liabilities”, it excluded claims arising from the use of “motorised vehicles”. So they wouldn’t refund the money he’d paid out for the repairs to the snowmobile.

Unhappy with this response, Mr K complained to his bank - who he’d bought the policy from. He said that he’d paid extra for winter sports cover - and expected to be covered for all winter sports.

The bank told Mr K that as none of their staff had spoken to him about the policy, they didn’t feel they’d done anything wrong - but that he could complain to the insurance company if he wasn’t happy with their decision. When he contacted the insurer again, they said that the policy documents clearly set out what they weren’t prepared to cover - and so they weren’t willing to change their mind.

Frustrated - and still unsure which business was responsible - Mr K contacted us.

complaint not upheld

We asked Mr K how he’d bought the insurance. He said he’d picked up an application form in a branch of his bank on his way out. He said he didn’t really have a problem with anything the bank had done - but he was angry that no one had let him know about the exclusion.

To see whether Mr K had been given clear information about what the policy covered, we asked the travel insurer to send us a copy of policy documents that he’d been sent.

From the paperwork, we saw snowmobiling was listed under the winter sports that the policy covered. But next to the word “snowmobiling”, there was an asterisk. And directly underneath the list of sports - on the same page - was a note saying that the policy’s “personal liability” cover excluded claims arising from the use of “any form of motorised vehicle”. In our view, this exclusion was clearly set out. We thought that Mr K must have just overlooked it.

We explained to Mr K that his policy would have covered his medical fees if he’d been hurt in the accident. But we took the view that the policy wording was clear that the cost of the damage to the snowmobile - his “personal liability” - wasn’t covered.

We also explained that, based on the cases we see, we didn’t think this sort of exclusion was unusual in travel insurance policies. So in our view, the insurer could rely on the exclusion to turn down the claim - even though it hadn’t been specifically highlighted.

Mr K said, on reflection, he was glad he hadn’t needed to make a medical claim. He was disappointed - but said he’d double-check his insurance next time he was planning a trip.

123/5
consumer complains that travel insurer has rejected claim for cancelled course fees and flights

As part of his gap year, Mr E booked a three-month winter sports trip. A few weeks in - while he was snowboarding in New Zealand - he badly injured his ankle and was advised to rest it for several weeks.

Mr E’s schedule was tight - and he was due to start a skiing course in Canada the following week. Realising that his ankle wouldn’t be healed in time, he called his travel insurer to see if he’d be covered for the cost of cancelling the course. He also wanted to cancel his flight to Canada, and from Canada back to the UK.

Following the phone call, Mr E contacted the course provider in Canada to cancel his place, booked new air tickets and returned to the UK.

When Mr E later made a claim, the insurer offered him £2,000. Disappointed, Mr E explained to the insurer that the cost of the course alone was £6,000 - aside from the cost of the flights. But the insurer explained that the policy limit was £2,000 - and was clearly set out in the policy booklet Mr E had been sent.

Mr E made a complaint. He said that he’d been told when he phoned the insurer from New Zealand that all his costs would be met. He said that if he’d been told about the limit, he wouldn’t have cancelled his plans - and would instead have arranged for his brother to take his place on the snowboarding course, and to use the homeward flight from Canada.

However, the insurer refused to increase their offer - and Mr E asked us to step in.

complaint upheld

We asked the insurer for the recording of the call Mr E had made to them from New Zealand. But they told us that the call hadn’t been recorded because of a “technical error”. We explained that, without any clear evidence about what Mr E was told, we’d make our decision based on what we thought was most likely to have happened.

We asked the insurer for their records of Mr E’s complaint - and looked carefully at what Mr E had said about what he’d been told by the insurer. In our view, the accounts he’d given of the conversations he’d had were detailed and consistent. They were also consistent with the account he’d given us.

Mr E told us that his brother was also on a gap year, and could have easily flown out to Canada to take his place on the course. We contacted the ski school to find out whether they’d have accepted Mr E’s brother instead of Mr E - and they confirmed that they would have. We also confirmed with the airline that Mr E’s ticket was transferrable - or could have been used later in the year.

Taking all these facts together, we decided that it was more likely than not that Mr E hadn’t been told about the policy limit. We thought that if he had been told - given there were other options available - he wouldn’t have cancelled either the course or the flights, running up costs over £2,000.

We accepted that, because of the short timeframe, Mr E’s brother wouldn’t have got to Canada before the course began. We estimated he would have missed the first half of it - so we thought it was fair to tell the insurer to pay halfthe course fees.

We also told the insurer to cover the full costs of the cancelled flights, which Mr E could have used or transferred if he’d known about the policy limit. We said 8% interest should be added to the money Mr E was owed.

123/6
consumer complains that insurer has rejected claim for UK medical costs - after skiing accident abroad

Miss L was skiing with her sister in Canada when she fell and badly hurt her back. She was taken by snow cat back to the resort, where she was seen by a doctor. On the doctor’s advice, she received treatment at a Canadian hospital.

When Miss L was back in the UK, she saw a consultant at her local private hospital - who recommended a course of treatment. Miss L had travel insurance with winter sports cover - and phoned the insurer to explain what had happened. Following this conversation, she arranged further consultant’s appointments, scans and physiotherapy relating to her back injury.

When Miss L claimed for her medical costs, the insurer agreed to pay for the treatment she’d had in Canada - as well as what she’d had back home. But although the insurer said they’d pay for her physiotherapy in the UK, they refused to pay the consultant’s and scan fees - saying that their policies didn’t include “specialist treatment” in the UK.

Miss L thought this was unfair - and made a complaint. She said that she remembered listing the treatment she wanted to have when she phoned the insurer. And she remembered the person she spoke to telling her that her claim would be paid.

However, the insurer wouldn’t change their position - and Miss L asked us to step in.

complaint upheld

We asked the insurer for a copy of the terms and conditions of Miss L’s policy. Under the heading “What you are not covered for”, the policy listedtreatments you receive within Great Britain except for claims payable under Section 14”. Section 14 was “physiotherapy”.

Based on this, it looked like part of Miss L’s claim was excluded. But we needed to establish what she’d been told about her claim - and whether the insurer could have warned her earlier on that they wouldn’t pay for specialist treatment once she was home.

We asked for the insurer’s records of all the contact they’d had with Miss L. We saw that the day after her accident, Miss L had sent the insurer an email - explaining that: “I may need to have a scan and see a specialist - depending on how I recover over the next week”.

It wasn’t clear from this email that this specialist treatment would happen once Miss L was back home. So we didn’t think the insurer hadn’t done anything wrong by not mentioning the policy’s exclusions at that stage.

But we also listened to the phone call between Miss L and the insurer - which happened around a month after her accident. In this call, Miss L explained that she was now back home - and went on to ask whether she’d be covered for various specific treatments.

At one point, she asked, “But what about the specialist appointment?” The insurer asked if the appointments were related to Miss L’s skiing injury. When she said yes, she was told:

As long as you have the paperwork, that’s something we can definitely look at for you … and we’ll have the claim to you shortly.”

Miss L had clearly been concerned to know exactly what was and wasn’t covered. And she’d mentioned the particular treatment she had planned. We thought the insurer should have told her during the call that some of these costs wouldn’t be covered. In our view, it was reasonable that Miss L had relied on what the insurer had told her.

We thought it was unlikely that Miss L would have gone ahead with the private specialist treatment if she’d known she’d have to pay for it. In the circumstances, we decided that the insurer should pay Miss L’s claim, adding interest.

However, we saw that Miss L had already run up the cost of a consultant’s appointment before phoning the insurer to check whether she was covered. We thought she could have contacted the insurer before this appointment. So we only asked the insurer to cover the cost the treatment that Miss L had received after the phone call.

image: ombudsman news

ombudsman news gives general information on the position at the date of publication. It is not a definitive statement of the law, our approach or our procedure.

The illustrative case studies are based broadly on real-life cases, but are not precedents. Individual cases are decided on their own facts.