Policyholder complains when her insurer rejects claim for total and permanent (TPD) benefit

Critical Illness

Following surgery, Tammie developed a pain condition and was unable to work. We investigated when her insurer turned down her claim for TPD benefit because they believed there was no pathological cause.

What happened

Tammie made a claim for a total and permanent disability (TPD) benefit after her back surgery. Following the surgery, she developed and was diagnosed with a pain condition, which stopped her from working. Her insurer investigated Tammie's claim, but wouldn't pay it. They said there was no pathological cause for her symptoms, so they didn't know if her symptoms would improve.

Tammie decided to complain. She said her consultants believed she wouldn't be able to return to any kind of occupation in the future. They also said that she'd continue to be restricted by a total and permanent disability.

What we said

We looked at the terms of Tammie's policy. We needed to see what the TPD definition she was being assessed by was.

In her policy, it said that Tammie had to be permanently and totally unable to perform any occupation - and remain that way for the rest of her life. We noted that the policy definition didn't say anything about there needing to be a pathological cause for Tammie being unable to work. This contradicted what Tammie's insurer had said to her when they rejected her claim.

When we looked at the medical evidence in Tammie's case, it was clear her functional abilities had deteriorated for many years. This was despite her undergoing several treatments. None of Tammie's consultants felt that she would get better to the point where she could work in any occupation.

We decided to uphold Tammie's complaint as we felt she did meet the criteria for her claim.

We told Tammie's insurer to pay her claim with 8% interest per year from when we believed the medical evidence proved the claim was payable. We also told them to refund any premiums since the claim became payable with 8% interest. This would date from when each premium was paid to the date of the settlement.

We also told Tammie's insurer to pay her £500 as compensation for distress and inconvenience.