Consumer complains that policy should pay out for similar condition even if not listed

Critical Illness

We took a look at Lori's complaint when her insurer wouldn't pay out on her policy because her exact condition wasn't listed.

What happened

Lori was suffering from many serious symptoms and had to go into hospital. She was diagnosed by her consultant with something like bacterial meningitis. Lori made a claim to her insurer under her critical illness policy. Her insurer assessed the claim, but declined it.

The reason they gave was that Lori wasn't diagnosed with an illness listed under her policy. They said that even though her condition was like one listed, they would only pay if one of the listed conditions in the policy was diagnosed.

Lori was very unhappy about this, so she came to us to complain. She 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. So she thought the insurer should make an exception and pay her claim.

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 which 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 didn't believe it was fair to ask a business to pay for an illness that wasn't listed.

Even though we understood from Lori's consultant that her condition was like one that was listed, we didn't think it would be fair to ask the insurer to pay out as Lori didn't have the required diagnosis. So we decided not to uphold Lori's complaint.