A customer complains that the definition of ‘accident’ in his policy means his claim is unfairly turned down

Personal Accident Insurance Insurance

Colin complained to us because his insurer declined his personal accident claim.

What happened

Colin tore a muscle in his shoulder while throwing a ball during a game of cricket. His insurer said the claim wasn’t covered because it didn’t think his injuries were caused by an accident as defined in the policy wording.

What we said

We started by reviewing the policy terms. Colin’s policy covered injury to the body caused by an accident. Colin’s policy stated:

‘Accident’ is defined as: ‘A sudden, unexpected and specific event, external to the body, which occurs at an identifiable time and place.’

Under this definition, the event that causes the injury has to be unexpected. We thought a cricket player would be expected to throw a ball at some point during a match. And while Colin may not have expected to injure his shoulder, the policy asks whether the event was unexpected, not the consequences of the event.

We didn’t find any evidence to suggest there was anything unusual or unexpected about the occasion when Colin threw the ball, other than him hurting his shoulder. So we didn’t think the circumstances of Colin’s injury met the requirements for an accident under the terms of the policy.

We told Colin we didn’t think the insurer had acted unreasonably – so we didn’t think the insurer should pay his claim.