Lori claimed on her critical illness policy but was told her condition wasn’t covered.
What happened
Lori was suffering from severe symptoms and had to go into hospital. She was diagnosed by her consultant with something similar to bacterial meningitis.
Lori made a claim to her insurer under her critical illness policy. Her insurer assessed the claim but declined it.
The reason the insurer gave was that Lori wasn't diagnosed with an illness listed under her policy. It said that although her condition was like one listed, it would only pay if one of the listed conditions in the policy was diagnosed.
Lori said that her condition was more serious than many of the listed illnesses. She also felt that many of her symptoms were like one of the listed conditions. Lori thought the insurer should make an exception and pay her claim, so she brought her complaint to us.
What we said
We looked at the medical evidence provided by Lori's consultant. It was clear that Lori had been critically ill. She'd been in hospital for a long time and was suffering from symptoms that may affect her for the rest of her life.
When we looked at the policy's terms, we could see that Lori hadn't suffered one of the conditions covered in the policy. We understood from Lori's consultant that her condition was similar to one that was listed. But we didn't think it was fair to ask the insurer to pay out as Lori didn't have the required diagnosis.
We did not uphold Lori's complaint.