SERVICE: Health
OUTCOME: Not upheld
Issues: Scope of cover
Mr F held accidental injury cover with the insurer.
In January 2023, Mr F made a claim for an accidental injury benefit, because he had undergone ulnar nerve decompression, left guyon’s canal decompression and resection of mass surgery on his left wrist. Mr F said he required the surgery, because he had injured his wrist in an accident at work in July 2022.
The insurer declined the claim on the basis that Mr F had not proved he had suffered an “accidental injury” under the policy.
The case manager’s assessment
When making a claim under an insurance policy, the law says that it is up to the insured to prove that they have suffered a loss, which is covered by the policy (a prima facie claim).
This meant that Mr F had to show he had suffered an accidental injury requiring surgery under the policy.
The medical evidence showed that the surgery was required to remove a ganglion from Mr F’s wrist. While Mr F believed it was too coincidental for the ganglion to have appeared in the same place as his injury without being related to the accident, there was no medical evidence supporting him. Rather, one specialist had said that trauma can be associated with the formation of ganglion cysts, but she did not know whether that was the cause of Mr F’s ganglion. Another specialist said that the ganglion was not accident related.
Therefore, Mr F was unable to prove on the balance of probabilities that it was more likely than not that the ganglion was solely caused by an accident.
The IFSO Scheme could only consider whether the insurer had correctly applied the policy wording to the claim and could not require the insurer to make a payment to Mr F on a goodwill basis.
Complaint No: 00230339