DRN-6290785

The complaint Mr and Mrs G are unhappy with the service they received from U K Insurance Limited when Mrs G became unwell abroad. Mr and Mrs G are represented but I’ll mainly refer to them throughout my decision. What happened Mrs G became unwell whilst abroad and was admitted to a private hospital. She was transferred to a public hospital which had more appropriate facilities. Mr and Mrs G are unhappy that UKI initially said there was cover under the policy and then advised there wasn’t. Mr and Mrs G’s family arranged an air ambulance to repatriate her home. They complained to UKI about the overall service they’d received and wanted their expenses covered. In their final response letter UKI accepted they would pay costs up until the date they communicated their decision to terminate cover. They explained that they’d changed their decision about cover as they’d been made aware during the claim that Mrs G’s admission was linked to a pre-existing condition which was excluded. They paid £750 for the failings in the service provided, including delays in setting up the claim. Unhappy, Mr and Mrs G complained to the Financial Ombudsman Service. Our investigator looked into what happened and thought UKI’s decision to cover costs up until 19 March 2024 was fair. But she didn’t think they needed to pay any further compensation. She was satisfied that UKI had adequately explained their decision to stop covering the claim and that they weren’t responsible for delays in Mrs G returning home or needing an air ambulance. Mr and Mrs G didn’t agree and asked an ombudsman to review their complaint. In summary, they said that had the decision to decline the claim been made sooner they’d have made arrangements to get Mrs G home at an earlier opportunity. They highlighted examples of where they felt UKI had delayed the claim and said that UKI should pay a further £12 500 towards the costs of the air ambulance. The complaint was referred to me to make a decision. Having reviewed the details of the complaint I contacted Mr and Mrs G’s representative to let her know my initial thoughts about the outcome of the complaint. I clarified that I had reviewed the medical evidence related to the claim and explained that I didn’t think UKI were aware that the admission was linked to the pre-existing condition until around a week before UKI changed their decision about cover. I said that I thought it was reasonable that UKI had agreed to cover all the costs up until the point that decision was communicated to Mr G. And I explained that the medical records didn’t demonstrate Mrs G was well enough to return home at an earlier opportunity. The representative responded with detailed comments and queries. She felt that various concerns had not been investigated or considered. And she felt that obvious contradictions and concerns were being glossed over.

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I explained to the representative that the Financial Ombudsman Service is an informal alternative to the courts and that my initial thoughts were based on all the available evidence, including the records available and the testimony Mr and Mrs G had provided. I explained that I would review the further comments and make a final decision about the complaint. Finally, the representative said UKI didn’t have a defence to their position as ignorance of the law wasn’t a defence and it wasn’t acceptable that UKI didn’t know their own policies and procedures. The representative also said UKI could and should have asked on the first day of the admission if this related to Mrs G’s pre-existing medical conditions. She said that UKI didn’t misunderstand the situation as they were in possession of all the pertinent facts. So, I now need to make a final decision. What I’ve decided – and why I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint. The relevant rules and industry guidelines say that UKI has a responsibility to handle claims promptly and fairly. And they shouldn’t reject a claim unreasonably. I have a lot of empathy with Mr and Mrs G’s circumstances, particularly as they incurred significant costs to repatriate Mrs G home via air ambulance. I also appreciate the wider circumstances were traumatic and very difficult as Mrs G was very unwell whilst abroad. I also acknowledge that I’ve summarised this complaint in far less detail than Mr and Mrs G have, and in my own words. I won’t respond to every single point made. No discourtesy is intended by this. Instead, I’ve focussed on what I think are the key issues here. The rules that govern our service allow me to do this as we are an informal dispute resolution service. If there’s something I’ve not mentioned, it isn’t because I’ve overlooked it. I haven’t. I’m satisfied I don’t need to comment on every individual point to be able to fulfil my statutory remit. I’m sorry that Mr and Mrs G’s representative feels that certain points are being glossed over or not investigated. The Financial Ombudsman Service is not the regulator and considers individual complaints. Our role is to consider what, if anything, went wrong, what should have happened and, where there is detriment caused, direct a business to put things right. Unfortunately, it’s not always possible or appropriate to identify specific answers to the questions Mr and Mrs G may wish to know the answer to. For example, their representative raised concerns about UKI’s email systems, the cause of delays and other claim related processes. As I’ve outlined above there clearly were failures in this case but it’s not my role to provide answers to Mr and Mrs G about UKI’s internal procedures. I’m satisfied that I have enough information to decide whether UKI treated Mr and Mrs G fairly based on the overall circumstances of the case. Whilst that may not specifically answer all Mr and Mrs G’s queries and concerns I hope it reassures them that someone impartial has reviewed their complaint. Having considered Mr and Mrs G’s representations I’m not persuaded that UKI needs to do anything further to put things right. I say that because: • I think UKI acted reasonably based on the information that was provided to them by the treating hospital. The initial information indicated that Mrs G was being treated

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for chest problems rather than her pre-existing conditions. UKI is entitled to rely on that information, and I don’t think it was unreasonable for them to proceed on the basis that Mrs G was covered. • I appreciate that Mr and Mrs G’s representative feels that UKI should have probed whether the pre-existing condition was contributing to the illness with the treating team. However, UKI was entitled to rely on the information as presented to them by the treating hospital. And I wouldn’t expect UKI to actively look for reasons to decline a claim where, based on the available evidence, the admission was unrelated to pre- existing medical conditions. Around one week before the date UKI communicated their change in stance on cover they’d became aware that the admission was most likely linked to Mrs G’s pre-existing condition which was excluded from cover. So, I remain of the view that it’s unlikely, on the balance of probabilities, they could have declined the claim prior to that date • Furthermore, and in any event, UKI has agreed to cover the costs up until this was discovered and Mrs G continued to receive the treatment she needed. So, even if I accepted that UKI could have probed this further at an earlier stage, I don’t think it makes a material difference to the outcome of this complaint. Had the link been established sooner the outcome would have ultimately been the same. Cover would have been declined and Mrs G would have most likely spent time in hospital before being repatriated by her family at their own expense. • It’s accepted that UKI didn’t communicate the change in their decision to cover the claim until sometime later. There’s no clear explanation as to why that was. But, I don’t think it’s necessary to investigate the root cause of this further. As I explained the Financial Ombudsman Service is an informal service and it’s for me, as the deciding ombudsman, to determine what information I think is relevant and necessary. It’s not for the parties to determine the course of my investigation. In this case UKI has agreed to cover the costs of the claim up until the decision to decline it was communicated to Mr and Mrs G. I think that’s reasonable and so I’m not persuaded there was any financial detriment caused because of the delay. So, I don’t think it’s central to the outcome of the complaint what the reason for the delay was as it’s accepted there was one. • I’ve considered whether there was any detriment caused to Mr and Mrs G in terms of the delay in communicating the claim decision as their representative suggested that she could have been repatriated earlier. I don’t think that’s consistent with the overall medical evidence which indicates that at that time Mrs G was still very unwell and progressing slowly. The earlier medical evidence also doesn’t demonstrate that there was a window of opportunity to move Mrs G at an earlier date. So, whilst Mrs G’s family were able to repatriate Mrs G soon after the claim decision was made, I don’t think it means that they would have most likely been able to at an earlier date. • I’ve also considered that UKI didn’t manage Mr and Mrs G’s expectations about coverage being subject to ongoing review. Mr and Mrs G’s representative particularly highlighted UKI’s use of the word ‘guarantee’. This relates to the ‘guarantee of payment’ made for treatment. That’s a common term used within the travel insurance industry, and it relates to the agreement made between the insurer and treating facility to cover any expenses. I appreciate that UKI could have better managed Mr and Mrs G’s expectations about the ongoing review of cover during the claims process. However, I think that is fairly reflected in the compensation award already made rather than directing UKI to settle the claim. • I don’t find, on the balance of probabilities, that UKI was responsible for delays in

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repatriating Mrs G in the way that their representative has suggested. Given that they’ve agreed to cover the expenses covered under the policy up until the date the decision was reversed, I’m not persuaded there was any financial detriment caused to Mr and Mrs G because of any failings I’ve identified. That’s because, ultimately, once the link to the pre-existing condition was identified the cover would have been declined and the family would have needed to arrange the repatriation at their own expense. • Having considered the failings that have been accepted by UKI, and my findings outlined above, I think a total of £750 compensation is fair and reasonable in the circumstances. It’s clear that the poor communication in particular caused considerable distress, upset and worry to Mr and Mrs G during the time they were abroad and when the decision about cover was changed. I accept this had an impact on them at an already difficult time. I think £750 compensation fairly reflects the impact on them. But, as I don’t think UKI acted unreasonably in relation to the decision to change their position in relation to cover under the policy, I can’t fairly direct them to pay a further £12 500 towards the cost of the air ambulance as they’ve requested. My final decision I’m not upholding this complaint as I think UKI has done enough to put things right here. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr G and Mrs G to accept or reject my decision before 28 May 2026. Anna Wilshaw Ombudsman

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