SERVICE: Trauma
OUTCOME: Not upheld
Issues: Scope of cover
Mr Q had trauma insurance.
Ms W made a claim to the insurer, because Mr Q suffered hearing loss in one ear.
The insurer declined the claim, saying that Mr Q’s condition did not meet the criteria for an acceptable claim. It said the original policy only provided cover for permanent hearing loss in both ears, and the criteria of the new policy had also not been met.
The new policy required that an insured, as a result of sickness or injury, suffered hearing impairment on one ear which, whether aided or unaided, resulted in an average hearing threshold in one ear of 91db or greater, as measured at 500, 1000 and 1500 Hz.
Ms W made a complaint, saying that Mr Q’s hearing loss did meet the required thresholds when in an unaided state.
The case manager noted that the insurer declined the claim because, with a cochlear implant, Mr Q’s hearing impairment did not reach the required threshold. However, Ms W said that the phrase “whether aided or unaided” meant that the criteria would be met if Mr Q’s impairment met the thresholds in an unaided state or in an aided state (i.e. with the cochlear implant).
The insurer said that the idea Mr Q could be described as having permanent hearing loss in one ear, when he had undergone treatment which made him able to hear in that ear, was contradictory.
The case manager’s assessment
When interpreting a contract, the IFSO Scheme considers, among other things, the intention of the parties, commercial common sense, the natural and ordinary meaning of the words, the contract as a whole, and the context in which the words appear. The more reasonable construction will be preferred and, in the last resort, if the contract is ambiguous, the policy is to be interpreted against the party which wrote the contract.
The case manager did not agree with Ms W’s interpretation. They found the policy criteria required Mr Q to have a hearing impairment, both in unaided and aided states. That is, his hearing had to have been impaired to the stated levels, even in an aided state.
The insurer correctly applied the terms and conditions of the policy to the claim.
Complaint No: 00231224