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ombudsman news

issue 143

January 2018

travel insurance

Official figures show that more than 21.9 million UK residents went on summer holidays abroad last year. By comparison, we dealt with around 3,000 complaints about travel insurance in 2017 – deciding in nearly four in ten cases that the insurer in question hadn’t treated their customer fairly. This suggests that things go to plan most of the time – or at least, that holidaymakers can resolve any problems directly with their insurers.

However, trips away don’t always go smoothly. The case studies in this issue illustrate the wide range of problems that can lead to travel insurance claims – ranging from political unrest to serious accidents. While people can spend a lot of time planning a holiday, travel insurance might not always be a priority. But if something goes wrong, having chosen the right cover can prove to be much more important than deciding what outfits to pack.

Likewise, if insurers treat their customers fairly – looking at all the individual circumstances when considering a claim – it can make a significant difference to the people involved, in what may be very upsetting situations.

what types of complaints do you see?

We sometimes see travel insurance complaints involving advice, sales and administration. But, unsurprisingly, most of the complaints we see centre on claims.

In some cases, the claim in question has been made before the holiday has even begun – when someone cancels their planned trip. As our case studies show, whatever the reason for the cancellation, our job is to decide whether the insurer has applied the terms of the policy fairly.

We also see travel insurance complaints relating to specific types of holiday activities, such as winter sports or cruise breaks. The high risk of serious injury, sometimes in remote locations, can lead to claims being complex and expensive – so insurers are likely to be specific about what they’ll cover.

If we think a policy term is unclear – or if the insurer has applied it in an unfair and unreasonable way – we may say a claim should be paid, even if the circumstances aren’t strictly covered.

Insurers sometimes tell us they believe their customer’s excessive drinking led to a claim – and because of this, they won’t pay out. But if someone’s been honest about the fact they’d had a drink, we wouldn’t just assume they’d been drinking to excess – or that their drinking was necessarily the reason for their claim.

We sometimes need to remind insurers that it’s for them to show that any exclusion applies, rather than for their customer to show that it doesn’t. And we’ll expect to see the evidence – which is often medical evidence – that the insurer has relied on to reach the decision they have.

how do you put things right?

Unpicking these complaints can be challenging. There may not be as much evidence available if something’s happened abroad, compared with claims in the UK. We’ll reach our conclusions on the balance of probabilities – deciding, in all the circumstances and given everything we’ve seen, what we think is most likely to have happened.

If we decide a claim has been unfairly rejected, we may tell insurers to add 8% simple interest when they pay it – for example, if someone had to pay their medical expenses themselves, so were wrongly left out of pocket.

travel insurance case studies

  • 143/1 - Mr P complains that insurer won’t refund holiday medical fees on grounds he was drunk
  • 143/2 - Mr N complains that insurer has turned down claim for medical fees, saying alcohol caused the claim
  • 143/3 - Miss R complains that travel insurer won’t pay whole claim – saying she fell over because she’d been drinking
  • 143/4 - Mr and Mrs L complain that insurer won’t cover hospital fees following holiday illness
  • 143/5 - Mrs G complains that travel insurer won’t pay back cost of skiing holiday when she isn’t fit to ski
  • 143/6 - Mrs V complains that travel insurer won’t pay her claim – disputing the definition of a toboggan
  • 143/7 - Mrs P complains after insurer turns down travel insurance claim following husband’s serious skiing injury
  • 143/8 - Mr K complains that insurer has turned down cancellation claim after Foreign and Commonwealth Office issues travel advice
  • 143/9 - Miss D complains after parents’ travel cancellation claim is rejected because of age limit
  • 143/10 - Mrs M complains that insurer hasn’t paid her enough after she broke her arm on a cruise holiday

Mr P complains that insurer won’t refund holiday medical fees on grounds he was drunk

Mr P, in his twenties, phoned us after his insurer had turned down his claim for hospital fees following an accident on holiday. His insurer was saying he’d been drinking excessively when the accident happened, so his travel insurance policy didn’t cover him.

Mr P explained he’d been on a beach holiday with his friends when he’d slipped over in the toilets of a nightclub and hit his head. He said that he’d gone back to his table after the fall and told his friends what had happened – but that they hadn’t been worried at the time, as he’d seemed fine. However, he’d woken up with a headache and dizziness the next day – and had felt worse as the day went on.

Mr P said he hadn’t been sure what to do, so he’d contacted his insurer. They’d advised him to go to hospital, where he’d had some tests and been given some medication. But when he’d made a claim for his medical costs, the insurer wouldn’t pay out because he’d told them he’d been drinking.

Mr P remembered telling the insurer when he’d phoned them that he’d had some alcohol before the accident – but insisted he hadn’t been drunk at the time. He said he’d had some food and a couple of drinks, but nothing excessive like the insurer was saying. He thought the insurer was acting unfairly, and asked for our help to sort things out.

putting things right

We looked at the terms and conditions of Mr P’s travel insurance policy. These said the insurer didn’t expect policyholders to avoid alcohol on holiday – but said claims wouldn’t be covered where the policyholder was so drunk their judgement was affected. The policy said one example of this would be where, in the treating doctor’s opinion, “excessive alcohol” had caused or contributed to the injury.

We asked the insurer to point us to any evidence they had to show excessive alcohol was likely to have been the cause of Mr P’s claim. We pointed out that the medical reports from the hospital abroad said Mr P had a head injury – and the scan and blood test results were normal. Once he was back home, his GP had told him he’d probably been concussed. We reminded the insurer that it was for them to show the exclusion applied, rather than for Mr P to show that it didn’t.

The insurer said that because Mr P didn’t go to hospital until the following morning, the alcohol might not have still been in his system – so it wouldn’t have shown up in any tests. They also pointed out that Mr P had told them he’d been drinking.

We considered what Mr P had told us – and the insurer – about how much he’d had to drink. We also took into account all the medical evidence.

We acknowledged that Mr P had drunk some alcohol. He wasn’t disputing that. But, on balance, we didn’t think the evidence showed it was more likely than not that excessive alcohol consumption had caused his accident.

Because of this, we didn’t think it was fair or reasonable for the insurer to turn down Mr P’s claim. So we told them to pay the costs Mr P had paid out for his medical treatment, plus interest at 8%.

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Mr N complains that insurer has turned down claim for medical fees, saying alcohol caused the claim

Mr N contacted us after his claim on his travel insurance policy was turned down. He said he’d fallen and hit his head while on holiday – but his insurer had rejected his claim, saying he’d had too much to drink when it happened.

The insurer had told Mr N that his policy didn’t cover claims arising from excessive alcohol consumption. But Mr N argued that the policy didn’t define “excessive”. He also said he’d tripped over in his room – which could have happened to anyone, regardless of whether they’d been drinking. He felt the insurer was being unfair and asked us to sort things out.

putting things right

We asked the insurer what evidence they’d relied on when turning down Mr N’s claim.

They sent us medical records showing the emergency doctor diagnosed Mr N with “acute alcohol intoxication” – alcohol poisoning. These records also said Mr N hadn’t been able to sign a form when he arrived at the hospital – with the reason given that he was “under the influence of an intoxicant”. Other records made during his trip in the ambulance suggested he’d said he’d been drinking all night.

Mr N said the hospital didn’t carry out any tests – and that his friends would back up the fact he hadn’t drunk that much.

However, we thought there was enough medical evidence to decide, on balance, that his accident was likely to have been caused by excessive alcohol – and that the accident wouldn’t have happened otherwise. When we explained this to Mr N, he accepted our view.

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Miss R complains that travel insurer won’t pay whole claim – saying she fell over because she’d been drinking

Miss R wanted to dispute her insurer’s decision about her travel insurance claim. She explained that her knee had come out of its joint while she was on holiday. Following a number of scans in a foreign hospital, she’d ended up with her leg in a cast – and ended her trip early. But the insurer refused to pay her claim, saying the problem related to alcohol.

Miss R disagreed with this. She accepted she’d had something to drink that night, but didn’t think alcohol was to blame for what had happened. She said she’d recently been told she had a joint condition. However, the insurer was refusing to change their mind – and Miss R wanted our help.

putting things right

We asked the insurer for their records about the claim. We saw Miss R had said on her claim form that she’d had something to drink on the night her knee came out of joint. And the insurer was saying the injury wouldn’t have happened if Miss R hadn’t been drinking.

We asked Miss R for more information about what had happened. She explained she’d been walking back to her hotel following a night out on holiday, when her knee had come out of joint and she’d fallen over. She said she’d got a taxi back to her hotel – but had ended up going to hospital. Miss R said that, since getting home, she’d been told she had a condition that meant her joints were prone to dislocation. She sent us a letter from her GP confirming this.

We then considered the evidence from the time of the injury. The hospital report said there was no sign of an impact to Miss R’s knee – which we thought suggested it had dislocated before she fell, rather than doing so because she’d fallen on it. And there wasn’t anything in the hospital report to suggest alcohol was to blame.

We told the insurer that, based on the information we’d seen, we thought it was more likely than not that the injury would have happened regardless of whether Miss R had drunk any alcohol. We asked them to send us any evidence they had that showed Miss R’s drinking alcohol was likely to have led to her injury.

The insurer didn’t provide any evidence. In view of our investigation, they accepted what we’d said and agreed to pay Miss R’s claim.

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Mr and Mrs L complain that insurer won’t cover hospital fees following holiday illness

Mrs N contacted us on behalf of her elderly neighbours, Mr and Mrs L, who were having trouble with their travel insurance claim. She said Mr L had become seriously ill while on holiday. He’d ended up in a private hospital – and the insurer was refusing to pay the fees.

Mrs N said that Mrs L had been given misleading information by the insurer – and was still very distressed about the whole thing. She asked if we could look into what had happened and tell them what to do.

putting things right

We asked the insurer for all their records – and asked Mrs N for more detail about what had happened to Mr and Mrs L.

Looking at this evidence, we began to get a clearer picture. Mr L had been told he needed urgent hospital treatment, and had been taken away in an ambulance. Mrs L had phoned the insurer the following day to let them know he was receiving private care. At this stage, the insurer hadn’t mentioned the fact they wouldn’t pay for private care costs. Two days later, the insurer called back to say Mr L would need to be moved when he left intensive care, as private care wasn’t covered by the couple’s policy.

Mr L had needed a further week in intensive care before his treating doctor confirmed he was fit to be moved– and was then taken to a public hospital. It seemed Mrs L had also had trouble getting the information she needed from the insurer about hotel arrangements near the hospital.

We carefully reviewed Mr L’s policy documents. Like most travel insurance policies, these said private medical treatment wasn’t covered. And we thought this term was clearly set out in the policy.

However, we saw that the doctor who first examined Mr L had said his condition was life-threatening – and he needed urgent treatment. The medical advice was that Mr L needed to be taken to the nearest hospital with an intensive care unit. And it turned out that the closest hospital to where Mr L was staying was a private one.

We accepted that, applying the policy terms strictly, Mr L’s claim for private medical treatment wasn’t covered. And Mr and Mrs L should have called the insurer before Mr L received any treatment.

But in the circumstances, we could see why the couple had acted on the medial advice they received. And we understood why, because of the situation they were in, they hadn’t had the opportunity to phone their insurer until the next day. We also concluded, looking at the evidence, that Mr L had been moved to a public hospital at the first available opportunity.

We recommended that the insurer pay the private medical costs Mr and Mrs L had already paid for, as well as the accommodation expenses Mrs L had run up as a result of Mr L being in hospital – adding interest.

We also recommended that the insurer compensate the couple for the trouble and upset they’d experienced as a result of the way their claim had been handled. The insurer agreed this was a fair way forward. In all circumstances, we judged the compensation should fall within the moderate range – as explained on our website.

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Mrs G complains that travel insurer won’t pay back cost of skiing holiday when she isn’t fit to ski

Mrs G contacted us after cancelling her skiing holiday. She’d provided her travel insurer with a medical certificate showing she had tendonitis – and her doctor’s opinion that she couldn’t ski.

However, the insurer had said even though Mrs G couldn’t ski, she’d still have been able to travel and enjoy her holiday. So they wouldn’t cover the cost of the cancelled trip. Mrs G thought this was unfair, and asked for our help to sort things out.

putting things right

We contacted the insurer to ask for their side of the story. They repeated Mrs G wasn’t covered under her policy. The policy said cancellation was covered if the policyholder became seriously ill or injured – and that a medical certificate was needed to support the reason why the policyholder couldn’t travel. The insurer said Mrs G’s doctor hadn’t specifically said she couldn’t travel – only that she was unfit to ski.

We could see that Mrs G’s doctor had completed the questions on the insurer’s form. The doctor hadn’t specifically been asked to distinguish between Mrs G being fit to ski and being fit to travel. However, the doctor had said they’d certify that Mrs G was compelled to cancel her trip.

We considered the medical evidence Mrs G had provided. And, importantly, we took into account that the whole purpose of Mrs G’s holiday was to ski. Now she wasn’t able to do that, we didn’t think it was fair or reasonable for the insurer to strictly apply the policy terms and conditions to the circumstances of her claim.

In light of this, we told the insurer to pay Mrs G’s cancellation claim, adding interest.

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Mrs V complains that travel insurer won’t pay her claim – disputing the definition of a toboggan

Mrs V got in touch after she injured herself on a ride at an alpine resort. She said her travel insurer wouldn’t pay her claim for medical fees and ruined clothes, saying she wasn’t covered under her policy for either tobogganing or for dangerous activities.

Mrs V said the ride was more like a rollercoaster than a toboggan. But the insurer didn’t agree – and Mrs V wanted our help to sort things out.

putting things right

We looked carefully at the policy terms and conditions – and the evidence we had about how Mrs V had hurt herself.

The resort’s website explained how the ride had been converted from an existing toboggan run. However, it now operated as a small cart fixed to a rail – something that was clear from the website’s photos. The website also said the ride was suitable for children aged three or over, provided they were accompanied by an adult. There was no mention that any protective clothing or equipment was required.

We acknowledged that the insurer’s policy clearly listed tobogganing as a winter sport – and Mrs V didn’t have cover for it. However, we agreed with Mrs V that going on this particular ride wasn’t the same as “tobogganing”. And, based on the evidence we’d seen, we didn’t think it was fair to classify the ride as a “dangerous activity” either.

When we explained this to the insurer, they said they’d pay Mrs V’s claim for her medical expenses and damaged clothing, adding 8% interest.

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Mrs P complains after insurer turns down travel insurance claim following husband’s serious skiing injury

Mr and Mrs P complained to us when their insurer rejected their travel insurance claim. They explained Mr P and a friend had been skiing off-piste – when Mr P had had a serious accident. He’d severely injured his back and had a long stay in hospital in the country he’d been skiing in.

Mr and Mrs P explained they’d contacted their travel insurer to claim back the medical expenses under their policy. But the insurer had said skiing off-piste without a guide was a “hazardous activity”, so it wasn’t covered.

The couple had already complained to the insurer – but the outcome hadn’t changed. Increasingly distressed, they asked us to step in to sort things out.

putting things right

We asked the insurer for their side of the story – and for all the information they had, including the policy terms and conditions. The insurer told us that they knew their policy terms didn’t specifically mention off-piste skiing as an “excluded” or “hazardous” activity – but that the list in the policy documents wasn’t exhaustive. They said that if Mr P was going to go off-piste, he should have checked beforehand that he was covered.

Mr and Mrs P insisted Mr P hadn’t been carrying out a hazardous activity when he’d had his accident. They sent us information showing Mr P and his friend had been visiting and skiing in that area for decades, and also regularly went mountaineering there.

We considered whether the policy was clear enough. The policy said participation in any specifically excluded or hazardous activities would be excluded from cover, unless the insurer had confirmed otherwise. It also said the policyholder should contact the insurer if they had any plans to take part in any listed activity.

We acknowledged what the insurer had said about the list of excluded or hazardous activities not being exhaustive. However, we didn’t think it was fair for the insurer to put the burden on their customers of deciding what exactly an excluded or hazardous activity might be. So, in our view, the insurer couldn’t rely on the list to turn down Mr P’s claim.

On the other hand, the policy did say that off-piste skiing should only be done with an instructor. There was also a term saying policyholders should take reasonable steps to avoid accidents and avoid deliberately exposing themselves to danger.

We considered the reasons why an insurer might exclude cover for off-piste skiing without an instructor. We acknowledged that, in general, having an instructor would be likely to lessen the risk that someone who wasn’t familiar with skiing off-piste would injure themselves while doing it.

We then took Mr P and his friend’s particular circumstances into account. The evidence we’d seen suggested they had a significant level of skiing experience and familiarity with the area. In that light, it seemed likely they’d have a relatively similar level of knowledge to a guide or instructor.

So we didn’t think it was fair or reasonable to say that, in being off-piste, Mr P had exposed himself to danger. And we decided the insurer should pay the claim in full, adding interest to reflect the fact that Mr and Mrs P had already paid the medical costs themselves.

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Mr K complains that insurer has turned down cancellation claim after Foreign and Commonwealth Office issues travel advice

Mr K complained to us after his insurer turned down a claim on his travel insurance policy.

He explained he’d booked a trip abroad with his wife to visit her family. A few weeks before travelling – aware that there’d recently been political unrest in the country in question – he’d checked the Foreign and Commonwealth Office’s (FCO) website for official advice.

Mr K said the FCO’s website had advised against all but essential travel, because of increased levels of violence. And because of this, he’d decided to cancel the holiday. However, the insurer wouldn’t pay his claim – saying his policy didn’t cover cancellation resulting from wars, uprisings, civil unrest and revolutions.

Mr K said he’d complained to the insurer, pointing to the FCO guidance. The insurer had responded to say they believed their decision was correct. But Mr K disagreed, and asked for our view.

putting things right

We got in touch with the insurer to get the full picture about their decision. They sent us a copy of the policy terms and conditions, highlighting the exclusions they’d relied upon.

First, we considered the exclusion relating to civil unrest. The insurer said there’d been a number of media reports about the turbulence in the region in question – and it was reasonable to think Mr K should have been aware of these before booking his trip.

We acknowledged that Mr K’s claim fell under this exclusion on a strict reading of the policy. However, we saw there’d been coverage of public demonstrations around the time Mr K booked his holiday. In our view, Mr K couldn’t have been expected to predict things would deteriorate as they had. We didn’t think it was fair to say he should have known, at the point he booked, that he might need to cancel his trip.

We also saw there was a general policy exclusion for travelling to places where a UK government agency – or the World Health Organisation – had advised the public not to travel. In this particular case, the FCO had told people in the area in question to take great care, to avoid public gatherings, and to avoid all but “essential travel" to the region.

We agreed with Mr K’s judgement that a holiday wasn’t “essential travel”. It seemed Mr K had faced a choice between travelling completely uninsured to a high risk location, or cancelling the trip and having his cancellation claim turned down.

And we didn’t think it was fair or reasonable for the insurer to put Mr K in a position where he wouldn’t be covered if he did travel – but also wouldn’t be covered if he didn’t.

In these circumstances, we recommended that the insurer pay Mr K’s cancellation claim, together with interest at 8%.

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Miss D complains after parents’ travel cancellation claim is rejected because of age limit

Miss D contacted us about her parents’ travel insurance, which was included with their bank account.

She said that shortly before her parents were due to go on holiday, her father, Mr D, had been taken to hospital – and they’d needed to cancel their trip. But when they’d phoned the insurer to make a cancellation claim, they’d been told they weren’t covered as they were both over the policy age limit of 75.

According to Miss D, the insurer said her parents should have contacted them to say they were over 75. The insurer had said that, if Mr and Mrs D had contacted them, they would have then both needed to answer medical screening questions, and to pay more to remain covered under the policy. However, Mrs D was sure she had phoned the insurer before booking the holiday, and said she’d been told she and Mr D would be covered.

After Miss D complained, the insurer had looked back over their file. But they’d said they couldn’t find any record of Mrs D calling them. Miss D didn’t think her elderly parents had been treated fairly – and asked for our help to resolve things.

putting things right

We asked the insurer for a copy of the terms and conditions of Mr and Mrs D’s travel insurance – as well as all their records about the claim.

When we reviewed these records ourselves, we found a note confirming that Mrs D had phoned the insurer to check the details of their cover. We asked the insurer for a recording of this call. And when we listened to it, we heard Mrs D asking what her policy included. The insurer had outlined the main features of the policy – but hadn’t mentioned any issues with an age limit. So we thought it was reasonable, in the circumstances, that Mrs D had concluded that she and Mr D were covered.

We also asked the insurer how they’d communicated the age limit – to check whether it had been made clear to Mr and Mrs D beforehand. The insurer said they didn’t send reminders to their customers each year. They felt it was clear in the policy documents that people needed to contact them to confirm cover once they’d reached the age of 75.

We looked at the policy documents in question – and saw these said people over 75 needed to contact the insurer. However, we pointed out Mr and Mrs D had contacted the insurer. And the insurer could have taken the opportunity to discuss the age limit then – but they didn’t.

Having taken all the circumstances into account, we decided the insurer should cover the cancellation claim, adding interest. Because Mr and Mrs D would have needed to pay extra for their cover, we thought it was fair for the insurer to take this amount off the money they were paying for the claim.

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Mrs M complains that insurer hasn’t paid her enough after she broke her arm on a cruise holiday.

Mrs M told us about the problems she’d had with her travel insurance after breaking her arm on the second day of her cruise. She explained that, due to her injury, she hadn’t been able to enjoy the trip – especially as she’d had to cancel many of the activities she’d planned.

Mrs M said she’d contacted her insurer after her accident, and had decided to stay on the cruise rather than to go home. She’d also asked for the insurer’s help in upgrading her return flight, as she didn’t think she’d be able to travel comfortably in economy class with her arm how it was. She felt the insurer had messed her about – first saying they’d help, but later saying she wasn’t entitled to an upgrade.

It seemed the insurer had acknowledged the confusion about the return flights could have been avoided, and had offered Mrs M some compensation. They’d also offered to pay her medical costs from the cruise and the cost of the activities she’d missed.

But Mrs M thought the insurer should reimburse the full cost of her cruise – and compensate her for the pain and disappointment she’d felt while stuck in her cabin. She also wanted the insurer to pay for the medical treatment she’d had since she’d got back to the UK. She asked for our help to get things put right.

putting things right

Both Mrs M and the insurer sent us information about the claim and the costs Mrs M had incurred. We also asked the insurer for the terms and conditions of Mrs M’s policy – looking carefully at the cover Mrs M had had in place, and what her options had been.

Looking at the policy, it seemed Mrs M could have got the whole cost of the cruise back only if she’d cancelled the trip. Or she could have got part of the cost back if she’d cut her trip short. From the records we had, it looked like the insurer and Mrs M had explored all these courses of action at the time. And she’d decided to stay on the ship, saying she felt she was being looked after by the medical team on board.

We considered whether Mrs M’s trip had been effectively cut short – for example, whether she’d been required to stay in her cabin for the rest of the trip. But this hadn’t been the case. She’d been able to get out and about on the ship, including taking part in some of the activities she’d wanted to. All in all, we decided it was fair for the insurer to pay only Mrs M’s medical costs and expenses.

We explained to Mrs M that her travel insurance, like most policies, wouldn’t compensate her for loss of enjoyment or for being in pain. In line with the policy, the insurer had already offered to pay for the financial cost of the activities she’d missed. And we clarified that her policy only covered medical expenses abroad, not in the UK too.

We then looked into how the insurer had handled Mrs M’s request for a flight upgrade. In all the records about Mrs M’s injury and her claim, there wasn’t any evidence to suggest an upgrade would have been medically necessary.

So – although we acknowledged Mrs M felt she would have been better off with more space – we explained that we didn’t think it was unfair for the insurer to refuse to pay for the upgrade. And in our view, they’d already offered appropriate compensation.

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Image: ombudsman news 143

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.