Sinead held an insurance policy that would cover her if she was injured in or died from an accident that was the sole cause of her death.
Sinead fell and broke her hip. She was admitted to hospital and, after the operation to mend the hip, she became increasingly unwell to the point where she was unresponsive. A CT scan showed there had been a large bleed in her brain. Ten days after the accident, Sinead died. Sinead’s death certificate recorded the cause of death as:
- a large brain bleed
- a bleed in her lungs related to existing cancer
- a broken hip.
Sinead’s daughter, Patricia, was the executor of her mother’s estate, and submitted an insurance claim for loss of life following the broken hip.
The insurer declined the claim relying on their medical expert’s opinion that the primary cause of death was the brain bleed and so the accident was not the sole cause of death. Patricia did not accept the insurer’s decision and complained to FSCL.
Dispute
Patricia said that her mother died because she broke her hip. If she had not broken her hip, she would not have needed the operation that put her body under such stress that caused the brain bleed.
The insurer said the policy did not cover Sinead’s death because Sinead’s broken hip was not the sole cause of death. Based on medical advice, Sinead’s death was caused by the brain bleed that was unrelated to the accident and not covered by the policy.
Review
We could understand why Patricia challenged the insurer’s decision to decline the claim. If Sinead had not broken her hip, she would not have needed surgery that may well have contributed to the brain bleed that led to her death.
However, the policy wording required the injury to be the sole cause of death. While the broken hip set the scene, the death certificate and the medical expert both referred to a brain bleed as the primary cause of death.
Sinead had purchased a policy that would compensate her if she was injured in an accident and that injury was the sole cause of death. Sinead had paid premiums to the insurer based on this type of cover. The policy wording was not met, and it was not fair to expect the insurer to pay a claim that fell outside the policy wording.
Resolution
We decided that Patrica should discontinue her complaint. Patricia did not agree with our decision but did not give us any new information to cause us to reach a different decision.
Insights for consumers
Insurance policies have limitations. As a consumer you pay for a type and level of cover and the insurer is only obliged to pay a claim that falls within the policy wording. In this case, the medical evidence indicated that the accident causing the injury was not the sole cause of death.
