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In various industry meetings I’ve been a part of over the last decade AOB has often been an acronym for Any Ombudsman Bashing. It’s a surefire way to relieve the tension at the end of a meeting by moaning about someone not in the room.

Imagine my glee when directed by a friend to this month’s Ombudsman News for an introduction and six case studies on life and Critical Illness insurance. It sounded like an open goal for someone with my experience now freed from the corporate shackles and looking for things to voice a good strong opinion on.


Before I go on it is worth me stating that I do not know any more about these cases than is written in the newsletter. Of course it’s possible I may have underwritten these customers, or been involved in drawing up the disputed policy wordings, but I have honestly read these as an observer rather than an interested party.

I settled down ready to go, and found myself confused. Instead of getting angry and heated I was nodding and agreeing. A human and reasonable voice dominated, and the case studies fairly summarised the difficult decisions everyone involved in these situations faces.

There are two case studies that vividly illustrate the importance of understanding the definitions of the policies that you are buying. In one case FOS did not upgrade a definition to a better one that the insurer had introduced more recently, in another the policy wording was upheld over the claimant’s doctor opinion of what a heart attack definition should be.

Equally there are case studies that emphasise the importance to insurers of the wording they use. In both policy conditions and on application forms, considering how an individual would interpret or understand words is key. One case centres on health at the time of renewing a policy. This process is notoriously poorly managed from both a customer and risk perspective, and the resulting decision in favour of the claimant stems from this.

Fortunately the final case study offered the chance to at least raise an eyebrow if not enter full tub thumping rage. The dispute around whether the claimant had met the definition of a heart attack was decided in the claimant’s favour, in part “bearing in mind it’s for insurers to prove that policy exclusions apply, rather than for customers to prove that they don’t”.

This logic doesn’t seem applicable to this case. When claiming for a heart attack of specified severity the burden should be on the customer to show that they have had the event rather than the insurer to show they have not. I do not believe this is relying on an exclusion, rather applying the policy wording.

Notwithstanding this, I commend this newsletter to customers, advisers and insurers alike. It successfully highlights the serious nature of what we all do and the importance of getting the details right at every step to prevent unpleasant surprises for individuals or companies further down the line.

All of this positivity means I don’t even mind needing to find a new topic to end meetings on in the future!

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