Types of complaint we see
We might see complaints from customers about:
- the cost of medical treatment while out of the UK
- the cost of being flown home early for medical reasons (repatriation)
- other expenses like transport to and from hospital, relatives' travel costs and accommodation
- the insurer took too long to confirm cover
- the standard of medical care wasn’t good enough
- they should have been repatriated sooner – or in a different way
- they shouldn't have been repatriated
Insurers often tell us that they've rejected a claim because:
- the situation wasn’t a medical emergency – and treatment wasn’t necessary
- the claim isn't covered because it's linked to a pre-existing medical condition
Handling a complaint like this
As with any complaint, we’ll expect you to work with your customer to get to the bottom of what happened, investigate fairly whether anything went wrong, and – where appropriate – take steps to put things right.
If you don’t reply within the time limits for responding to a complaint, or the customer disagrees with your response, they can bring their complaint to us. We’ll check it’s something we can deal with, and if it is, we’ll investigate.
Read more about resolving complaints.
Information we will ask for when we receive a complaint
Once a complaint has been referred to us, we will ask you to provide information about your side of events.
The typical information we would normally expect to see about this type of complaint includes:
- policy schedule
- policy certificate
- full policy terms
- a timeline of the repatriation process
- medical reports from the treating hospital (in English)
- copies of the fit to fly certificates
- the full assistance file and/or claims handling notes
- reports/notes from the insurer’s medical team
- copies of call recordings
- copies of relevant quotes, for example for treatment or air ambulance
For complaints about medical claims, we would also expect to see:
- a copy of the claims notes and the medical assistance company notes
- a copy of any invoices/receipts if available
We may ask for further information or documents, depending on the circumstances of the case.
Read more about how we handle complaints.
What we look at
We’ll look at the policy wording and all the circumstances of the claim, including evidence provided by you and by your customer. We’ll take into account the relevant law, regulations and guidance and we’ll want to see that you treated your customer fairly in their particular circumstances.
You can find more detail below about some of the things we look at:
Most travel insurance policies state that the policyholder must make contact with the insurer before they incur medical expenses.
We don’t think a customer’s claim should automatically fail just because they didn’t contact you first. We’d look at:
- what the customer’s reasons were for not contacting you
- whether the medical expenses were necessary and reasonable – a lot of complaints involve treatment at private hospitals, but most travel policies only provide cover for treatment in public hospitals
- what you would have done if you had been contacted first
Travel insurance policies only cover emergency treatment that can’t wait until the customer returns to the UK.
Sometimes your Chief Medical Officer (CMO) and the treating doctor will have different opinions on the most appropriate treatment.
In these cases, we’d look at the medical evidence provided and your claims notes. We’d expect you to take into account the recommendations and advice of the treating doctor when making your decision. The treating doctor will have actually seen the patient at the time – so might be better placed to comment on your customer’s condition. But your CMO’s decision is a valid medical opinion so we’d take that into account.
A customer won’t be able to return to the UK until they have a fit to fly (ftf) certificate from the treating doctor.
We often see complaints where the treating doctor and the insurer disagree about:
- when the customer can be safely repatriated
- the transport which is medically appropriate for repatriation
We’d look at the medical evidence provided and your claims notes. We’d expect you to take into account the recommendations and advice of the treating doctor. Repatriation may involve travelling at altitude, which brings its own risks. Your medical officers will usually have a specialism in aviation medicine, so their views on whether to repatriate can be persuasive.
It’s our view that because your medical team have experience in repatriation medicine – they are well-placed to assess the customer’s repatriation needs. If there’s a difference of opinion, we’d expect to see that you’d discussed the situation with the treating doctor. You should make the decision on what is medically appropriate. If two options are appropriate, it’s not necessarily unfair for you to insist on the cheaper option, even if it does take a little longer – provided it doesn’t significantly impact the customer.
Most travel insurance policies only cover the cost of private treatment in limited circumstances.
A European Health Insurance Card (EHIC) entitles the cardholder to state healthcare in other EEA countries and Switzerland at a reduced cost or for free. Most travel insurance policies need the policyholder to have an EHIC card.
If you’ve turned down a claim for medical expenses because private treatment isn’t covered, we’ll look at whether:
- your customer was told about private treatment when they contacted you
- your customer chose to go ahead knowing private treatment might not be covered
- you offered your customer any help to move to a public hospital
- we think the customer’s actions were reasonable in the circumstances
We might think it was reasonable for your customer to use a private hospital if:
- they needed emergency treatment that couldn’t wait
- they were taken to a private hospital without being able to check with you first to see if this would be covered under their policy
- the treatment they needed wasn’t available in any public hospital within a reasonable distance from them
- the standard of care at a public hospital was so unacceptable, that it wouldn’t have been reasonable to expect the customer to remain there for treatment
- you didn’t explain clearly that treatment at a private hospital wouldn’t be covered
The standard of medical care varies from country to country. Although we’d expect you to look into any concerns raised by your customer, we’re aware that there’s very often little you can do about these concerns.
Insurers often negotiate with hospitals to reduce the amount they pay (cost containment). Cost containment is used in countries where medical costs are high. It’s also used to make sure insurers don’t face excessive fees in countries where treatment costs are low.
We sometimes see complaints about the exchange rate the insurer has used to pay the claim. If the customer has paid the hospital bills in a different currency, we’d usually ask the insurer to calculate the settlement based on the rate of exchange on the date the customer paid the expenses.
Customers often complain that their claim was delayed. We’ll consider your obligation under the Insurance Conduct of Business Sourcebook (ICOBS) rules to handle claims promptly and fairly.
We’ll look at:
- how long the delays were
- what caused the delays
- whether you could have reasonably done more to prevent or reduce the delay
- whether you kept your customer updated regularly
- the impact of the delay on your customer
Business Support Hub
If you want to talk informally about a complaint you've received, you can speak to our Business Support Hub. They can give general information on how the Financial Ombudsman might look at a particular complaint. We also offer guidance on our rules and how we work.
Find out how to contact the Business Support Hub.
Putting things right
If we think you have made a mistake or treated a consumer unfairly, we'll ask you to put things right. Our general approach is that the customer should be put back in the position they would have been in if the problem hadn't happened.
The exact details of how we'll ask you to put things right will depend on the complaint, and how the customer lost out. In some cases, we may also ask you to compensate the customer for any distress or inconvenience they've experienced as a result of the problem.
Insurer rejects a claim for medical expenses saying the illness was caused by alcohol
Consumer complains about insurer's handling of claim after bad experience on flight
Travel Insurance Distress and inconvenience Up to £5,000
Some of the guidance we take into account when we’re dealing with complaints include:
- Insurance Conduct of Business Sourcebook (ICOBS) and the rules on general and protection insurance products sales
- Customer Insurance (Disclosures and Representations) Act 2012