Hilary complains to us when she finds that she isn’t covered under the terms of her lifetime care policy, after a fall meant she needed full-time care in a nursing home.
Hilary had a lifetime care policy, which would pay a monthly benefit if she was unable to do three of a list of six defined activities of daily living, like being able to feed and dress herself.
She was admitted to hospital following a fall. On discharge from the hospital, it was decided that she was unable to return home and would need full-time care in a nursing home. So she made a claim under the policy.
The insurer arranged an independent medical examination but concluded that Hilary didn’t meet the policy criteria, so it declined the claim.
Hilary felt her insurer didn’t take everything into account and complained. Unhappy with how it handled her claim and its final response, Hilary approached our service and made a complaint.
What we said
We considered the insurer’s claim notes, the policy document and the independent medical examination.
Although the requirements for a claim to be paid were quite strict, the policy was clear. So we thought about whether the medical evidence showed Hilary had met the specific definitions for each activity.
As it was clear from the available evidence that Hilary only had problems with two of the ADLs, and not three as required by the policy, we were satisfied the insurer had correctly declined the claim. We didn’t uphold the complaint.
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