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ombudsman news

issue 13

January 2002

about this issue of ombudsman news

This edition of ombudsman news focuses mainly on health issues. Health-related complaints are an important aspect of our work. Private medical expenses insurance and permanent health cover account for about one in seven of the cases handled by the insurance division. But medical issues arise in a wider range of cases - from travel to loan protection.

Where disputes involve both health and money they can be highly charged. Understandably, policyholders will feel that they are best placed to judge many questions about their medical circumstances - for example - "am I fit enough for work-". Certainly most policyholders will prefer to listen to their own doctor's views about such issues rather than to the views of a medical adviser for the insurance industry. And that is particularly true when the question refers to whether a particular treatment is necessary or likely to cure the policyholder's medical condition.

In all these cases we need to look carefully at the often-conflicting medical evidence and reach a view about the policyholder's state of health - in some cases as it was several months before we became involved. Our role is to take a practical view of the policyholder's circumstances and to decide, on the basis of what is fair and reasonable, how the case should be settled. Policyholders' views - and those of their own medical advisers - will be important, but not decisive.

In this edition we consider four medical issues. First, in the case of policies sold on a group basis, we look at how far we should expect the insurer (as opposed to the employer) to inform people about policy terms and changes to conditions. Second, we consider how we should handle cases where, initially, the customer has a common general medical condition but it subsequently develops into something far more serious. Third, we look at some of the issues surrounding critical illness policies. Finally we consider the circumstances in which firms should pay for medical reports.

But we also cover a wider range of issues in a round-up of recent cases, ranging from dealing with a dead pet to whether a well-known children's hand-held game can be considered a "disk".

In many of the cases we deal with, we conclude that the firm might reasonably be expected to have resolved the complaint sooner and without the need for our involvement. We therefore comment on how we will interpret the new complaints-handling rules for firms.

Walter Merricks, chief ombudsman

ombudsman news gives general information on the position at the date of publication. It is not a definitive statement of the law, our approach or our procedure.

The illustrative case studies are based broadly on real-life cases, but are not precedents. Individual cases are decided on their own facts.